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SMITHSONIAN  MISCELLANEOUS  COLLECTIONS 

VOLUME  63,  NUMBER  1 


ATMOSPHERIC  AIR  IN  RELATION  TO 
TUBERCULOSIS 

(With  93  Plates) 


by 

GUY  HINSDALE,  A.  M.,  M.  D. 
Hot  Springs,  Virginia. 

Secretary    of  the    American    Climatological    Association;    Ex-President    Pennsylvania    Society    for    the 
Prevention  of  Tuberculosis;  Fellow  of  the  College  of  Physicians  of  Philadelphia;  Associate  Professor 
of  Climatology,  Medico-Chirurgical  College;    Member  of  the  American   Neurological  Asso- 
ciation;  Fellow  of  the  Royal  Society  of  Medicine,  Great  Britain;  Corresponding 
Member  of  the   International   Anti-Tuberculosis   Association,  etc. 


(Publication  2254) 


CITY  OF  WASHINGTON 

PUBLISHED  BY  THE  SMITHSONIAN  INSTITUTION 

1914 


ZU  Mort  (§a(timott  (pveee 

BALTIMORE,   MD.,  U.  S.   A. 


ADVERTISEMENT 

The  accompanying  paper,  by  Dr.  Guy  Hinsdale,  on  "  Atmospheric 
Air  in  Relation  to  Tuberculosis,"  is  one  of  nearly  a  hundred  essays 
entered  in  competition  for  a  prize  of  $1,500  offered  by  the  Smith- 
sonian Institution  for  the  best  treatise  "  On  the  Relation  of  Atmos- 
pheric Air  to  Tuberculosis,"  to  be  presented  in  connection  with  the 
International  Congress  on  Tuberculosis  held  in  Washington,  Sep- 
tember 21  to  October  12,  1908.  The  essays  were  submitted  to  a 
Committee  of  Award,  consisting  of  Dr.  William  H.  Welch,  of  Johns 
Hopkins  University,  Chairman  ;  Prof.  William  M.  Davis,  of  Harvard 
University;  Dr.  George  M.  Sternberg,  Surgeon-General,  U.  S.  A., 
Ret'd ;  Dr.  Simon  Flexner,  Director  of  Rockefeller  Institute  for 
Medical  Research,  New  York;  Dr.  Hermann  M.  Biggs,  of  New 
York,  General  Medical  Officer,  Department  of  Health,  New  York 
City;  Dr.  George  Dock,  Medical  Department,  Washington  Univer- 
sity, St.  Louis;  and  Dr.  John  S.  Fulton,  of  Baltimore,  Secretary 
General  of  the  Congress  on  Tuberculosis.  Upon  the  recommenda- 
tion of  the  committee,  the  prize  was  divided  equally  between  Dr. 
Guy  Hinsdale,  of  Hot  Springs,  Virginia,  and  Dr.  S.  Adolphus  Knopf, 
of  New  York  City. 

At  the  request  of  the  Institution,  Dr.  Hinsdale  has  revised  his 
essay  so  as  to  indicate  some  of  the  advances  made  in  the  study 
of  the  subject  during  the  past  five  years. 

Charles  D.  Walcott, 
Secretary  of  the  Smithsonian  Institution. 

Washington,  December,  1913. 


TERMS  OF  COMPETITION 

SMITHSONIAN  INSTITUTION 

HODGKINS    FUND   PRIZE 

In  October,  1891,  Thomas  George  Hodgkins,  Esquire,  of  Setauket, 
New  York,  made  a  donation  to  the  Smithsonian  Institution,  the  in- 
come from  a  part  of  which  was  to  be  devoted  to  "  the  increase  and 
diffusion  of  more  exact  knowledge  in  regard  to  the  nature  and  prop- 
erties of  atmospheric  air  in  connection  with  the  welfare  of  man." 
In  furtherance  of  the  donor's  wishes,  the  Smithsonian  Institution 
has  from  time  to  time  offered  prizes,  awarded  medals,  made  grants 
for  investigations,  and  issued  publications. 

In  connection  with  the  approaching  International  Congress  on 
.Tuberculosis,  which  will  be  held  in  Washington,  September  21  to 
October  12,  1908,  a  prize  of  $1,500  is  offered  for  the  best  treatise 
"  On  the  Relation  of  Atmospheric  Air  to  Tuberculosis."  Memoirs 
having  relation  to  the  cause,  spread,  prevention,  or  cure  of  tuberculo- 
sis are  included  within  the  general  terms  of  the  subject. 

Any  memoir  read  before  the  International  Congress  on  Tuberculo- 
sis, or  sent  to  the  Smithsonian  Institution  or  to  the  Secretary-General 
of  the  Congress  before  its  close,  namely,  October  12,  1908,  will  be 
considered  in  the  competition. 

The  memoirs  may  be  written  in  English,  French,  German,  Spanish 
or  Italian.  They  should  be  submitted  either  in  manuscript  or  type- 
written copy,  or  if  in  type,  printed  as  manuscript.  If  written  in 
'German,  they  should  be  in  Latin  script.  They  will  be  examined  and 
the  prize  awarded  by  a  Committee  appointed  by  the  Secretary  of  the 
Smithsonian  Institution  in  conjunction  with  the  officers  of  the 
International  Congress  on  Tuberculosis. 

Such  memoirs  must  not  have  been  published  prior  to  the  Congress. 
The  Smithsonian  Institution  reserves  the  right  to  publish  the  treatise 
to  which  the  prize  is  awarded. 

No  condition  as  to  the  length  of  the  treatises  is  established,  it  being 
expected  that  the  practical  results  of  important  investigations  will 
be  set  forth  as  convincingly  and  tersely  as  the  subject  will  permit. 

The  right  is  reserved  to  award  no  prize  if  in  the  judgment  of  the 
Committee  no  contribution  is  offered  of  sufficient  merit  to  warrant 
such  action.  Charles  D.  Walcott, 

Secretary  of  the  Smithsonian  Institution. 

Washington,  D.  C,  February  3,  1908. 


PREFACE 

The  rapid  progress  in  the  antituberculosis  movement  throughout 
the  world  in  the  last  five  years  has  made  it  necessary  to  make  some 
changes  in  the  present  essay  as  originally  presented  to  the  Smith- 
sonian Institution  in  1908.  Much  that  then  seemed  novel  appears 
almost  commonplace  now.  An  extraordinary  amount  of  research 
has  been  carried  out  with  reference  to  the  atmospheric  air  during 
these  later  years.  The  whole  theory  of  ventilation  has  been  stated 
in  new  terms;  the  presence  of  ozone  in  the  atmosphere,  a  subject 
that  has  always  appealed  to  the  popular  fancy  since  its  discovery, 
has  been  restudied  and  its  physiologic  action  assigned  a  value  differ- 
ent from  that  commonly  ascribed  to  it ;  the  properties  of  strong 
sunlight  and  Alpine  air  have  been  marshalled  for  the  combat  with 
surgical  tuberculosis,  particularly  in  children. 

Physiologists  in  Europe  and  America  have  lately  made  most  in- 
teresting studies  of  the  blood  at  the  higher  altitudes  and  their  obser- 
vations are  constantly  throwing  new  light  on  the  entire  subject  of 
aerotherapy,  replacing  old  impressions  and  beliefs  with  a  scientific 
basis  on  which  we  may  confidently  build. 

There  never  was  a  time  when  the  outdoor  life  and  the  accessories 
for  the  atmospheric  treatment  of  all  tuberculous  persons  were  so 
well  systematized  and  placed  in  harmony  with  the  other  hygienic 
measures  adopted  for  their  cure. 

What  the  result  has  been  we  have  endeavored  to  show  and  what 
the  future  holds  for  us  we  are  eagerly  awaiting. 

May  the  Smithsonian  Institution,  through  its  Hodgkins  Fund, 
continue  to  stimulate  inquiry  and  disseminate  the  fruits  of  the 
worldwide  efforts  to  the  better  understanding  of  the  great  problems 
that  yet  remain  unsolved. 

Guy  Hinsdale. 

Hot  Springs,  Va.,  December,  1913. 


TABLE  OF  CONTENTS 

CHAPTER  PAGE 

I.  Introduction   I 

Difficulty  of  estimating  the  value  of  atmospheric  air,  aside 
from  other  agents  in  treating  tubercular  disease;  prevention 
of  tuberculosis;  sanatoria;  pioneers  in  the  treatment  of  tubercu- 
losis in  America;  the  Adirondack  Cottage  Sanitarium. 

II.  Value  of  Forests  :    Micro-organisms,  Atmospheric  Impurities 4 

General  benefit  of  forests;  qualities  of  forest  air  and  soil;  car- 
bon dioxide ;  oxygen  ;  ozone ;  use  of  forest  reservations  for  sana- 
toria ;  micro-organisms  in  the  respiratory  passages ;  composition 
of  expired  air;  atmospheric  impurities,  coal  and  smoke,  carbonic 
acid,  sulphur  dioxide,  ammonia ;  oxygen  for  tuberculous  patients. 

III.  Influence  of  Sea  Air ;  Inland  Seas  and  Lakes 32 

Sea  voyages;  marine  climate  of  islands ;  Arctic  climate ;  float- 
ing sanatoria;  seaside  sanatoria  for  children;  seacoast  and  fogs; 
fogs  on  the  Pacific  coast ;  radiation  fogs ;  fogs  in  the  moun- 
tains;  sea  air  for  surgical  tuberculosis;  air  of  inland  seas  and 
lakes. 

IV.  Influence  of  Compressed  and  Rarefied  Air;  High  and  Low  Atmos- 

pheric Pressure ;  Altitude  61 

Discovery  of  the  advantages  of  Colorado  and  California  cli- 
mate for  consumptives ;  works  of  S.  E.  Solly,  Charles  Theodore 
Williams  on  Colorado ;  Jourdanet  on  Mexico ;  Paul  Bert  on 
diminished  barometric  pressure,  etc. ;  insolation ;  diathermancy 
of  the  air;  Alpine  resorts;  surgical  tuberculosis  treatment  in 
Switzerland;  cases  of  high  altitude  treatment;  effect  of  cold 
beneficial ;  expansion  of  the  thorax  at  the  higher  altitude ; 
choice  of  cases  for  treatment  at  altitudes. 

V.  Influence  of  Increased  Atmospheric  Pressure,  Condensed  Air 87 

The  effect  of  barometric  changes  on  the  spirits ;  artificially 
compressed  air,  C.  T.  Williams,  Von  Vivenot;  pneumatic 
cabinet;  Prof.  Bier's  treatment  of  surgical  tuberculosis  by  arti- 
ficial hyperemia. 

VI.  Artificial  Pressure ;  Breathing  Exercises 98 

Pulmonary  gymnastics ;  exercise  at  lowered  air  pressures ; 
atmospheric  compression  of  the  affected  lung,  Murphy's 
Method,  artificial  pneumothorax ;  song  cure. 

VII.  Fresh  Air  Schools  for  the  Tuberculous ;  Ventilation 103 

Waldschule  or  fresh  air  schools  for  tuberculous  children ; 
Providence  fresh  air  school;  defects  of  school  buildings;  hy- 
gienic safeguards  in  schools ;  rebreathed  air ;  open  air  chapels 
and  theatres;  ventilation  of  dwellings. 

ix 


X  TABLE   OF    CONTENTS 

PAGE 

VIII.  Exercise  in  Tuberculosis ;  Graduated  Labor hi 

Effect  of  exercise  on  the  opsonic  index  of  patients  suffering 
from  pulmonary  tuberculosis ;  work  of  Dr.  Paterson,  Mr.  In- 
man  and  Sir  Almroth  Wright. 

IX.  Accessories  for  Fresh  Air  Treatment  of  Tuberculosis  120 

Tents ;  pavilion  tents ;  tent  houses ;  shacks ;  disused  trolley 
cars;  balconies;  day  camps;  sleeping  porches;  pavilions;  hospi- 
tal roof  wards;  detached  cottages;  sleeping  canopies. 

X.  Conclusions 128 


ATMOSPHERIC  AIR  IN  RELATION  TO  TUBERCULOSIS 

By  GUY  HINSDALE,  A.M.,  M.  D.,  Hot  Springs,  Va. 

(With  93  Plates) 

CHAPTER  I.    INTRODUCTION 

We  are  compelled  to  acknowledge  at  the  outset  the  difficulty  or 
impossibility  of  analyzing  the  relationship  of  atmospheric  air  to 
tuberculosis  so  as  to  isolate  the  influence  of  all  other  factors.  It 
would  be  totally  useless  and  impossible  to  consider  air  independent 
of  sunlight,  heat,  rainfall,  the  configuration  of  the  earth's  surface ; 
racial  characteristics,  social  environment,  including  dwellings,  cloth- 
ing, food,  and  drink. 

As  a  resultant  of  all  these  and  many  other  factors  in  the  tubercu- 
losis problem,  we  obtain  the  figures  of  mortality  which  are  pub- 
lished from  time  to  time  by  various  cities,  states,  and  nations.  The 
problem  seems  incapable  of  solution.  One  might  as  well  survey  an 
oak  that  has  grown  for  centuries  and  set  out  to  determine  the  rela- 
tive value  of  the  atmospheric  air,  the  sunlight,  the  rainfall,  and  the 
various  constituents  of  the  soil  and  its  environment  in  producing 
the  sturdy,  deeply  rooted,  and  wide-spreading  tree  which  has  seen 
ages  come  and  go. 

The  world-wide  efforts  now  made  to  determine  the  nature  of  this 
infection  and  especially  its  bacteriologic  and  pathologic  character 
are  accompanied  by  a  general  effort  to  limit  its  spread.  We  are 
encouraged  to  believe  that  future  generations  will  be  provided  with  a 
practical  and  efficient  method  of  destroying  this  insatiate  monster. 

Undoubtedly  we  have  begun  at  the  right  end,  but  we  only  began 
within  the  memory  of  nearly  all  of  us,  only  thirty-two  years  ago, 
when  the  true  cause  of  the  disease  was  first  isolated  and  revealed 
to  the  human  eye. 

Previously  we  were  as  the  blind  leading  the  blind,  groping  about 
in  search  of  special  climates,  special  foods  or  medicines,  meeting 
with  more  or  less  success  in  so  far  as  the  dietetic,  hygienic,  out-of- 
door  plan  of  treatment  was  carried  out.  These  curative  measures 
succeeded   then,    as   they   succeed   now,   but  preventive   measures 

Smithsonian  Miscellaneous  Collections,  Vol.  63,  No.  1 

1 


2  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

worthy  the  name  were  entirely  unknown.  The  enemy  once  revealed 
in  its  hiding  place,  and  various  facts  in  its  life  history  determined, 
the  logical  result  was  a  gradual — very  gradual — dawn  which  prom- 
ised better  things.  Now  the  world  has  seen  a  great  light  and  we 
wonder  how  intelligent  men  could  have  dwelt  in  those  caverns  of 
ignorance  and  even  refused  to  come  out  for  years  while  the  men 
in  the  laboratory  beckoned  with  signs  which  then  seemed  so  uncer- 
tain but  now  so  clear.  As  late  as  1890  the  medical  mind  did  not 
grasp  the  necessity  for  preventive  measures.  As  one  asleep  it  heard 
voices  but  was  slow  to  waken ;  it  starts  and  rubs  its  eyes  and  looks 
about,  waiting  for  some  word  or  message  that  will  bring  it  to  its 
senses. 

It  was  in  1891  that  the  first  society  for  the  prevention  of  tuber- 
culosis was  organized.  This  was  started  in  France  by  M.  Armain- 
gaud,  of  Bordeaux.  The  second  was  the  Pennsylvania  Society 
for  the  Prevention  of  Tuberculosis  organized  in  Philadelphia  in 
1892.  These  were  the  pioneers  in  Europe  and  America.  They 
devoted  their  energies  to  a  campaign  with  three  cardinal  features : 
(1)  the  education  of  the  public  in  reference  to  the  nature  of  the 
disease  and  its  means  of  prevention;  (2)  the  passage  of  suitable 
laws  regarding  notification,  the  restriction  of  expectoration,  disin- 
fection, etc.;  and  (3)  the  care  of  consumptives  and  the  establish- 
ment of  sanatoria  by  public  or  private  means  in  suitable  localities. 

The  wonderful  growth  of  this  movement  for  preventive  measures 
is  now  seen  in  the  establishment  of  1,228  societies  for  the  prevention 
of  tuberculosis  in  America  alone,  and  in  the  erection  of  527  sanatoria 
in  this  country  (1913).1  The  State  of  Pennsylvania  alone  has  appro- 
priated in  one  Act  of  Legislature  $2,000,000  for  this  purpose  and 
one  citizen  of  the  state,  Mr.  Henry  Phipps,  has  given  an  equal 
amount  for  the  scientific  study  as  well  as  the  practical  treatment 
of  this  disease  in  all  its  bearings.2 


1  The  State  of  New  York  leads  all  other  states  in  the  number  of  new  organi- 
zations and  institutions  established  during  the  last  two  years.  The  total 
number  of  beds  for  consumptives  in  the  United  States  now  exceeds  33,000. 

2  The  Pennsylvania  legislature  appropriated  $1,000,000  in  1907,  $2,000,000 
in  1909,  $2,624,808  in  191 1,  and  $2,659,660  in  1913  for  tuberculosis  work  alone. 
This  is  under  the  direction  of  Dr.  Samuel  G.  Dixon,  the  Commissioner  of 
Health. 

There  are  at  the  present  time  two  State  Sanatoria  in  Pennsylvania  in 
operation. 

Mont  Alto,  Franklin  Co. 

No.  of  patients  under  treatment 957 

Elevation    1,650  ft. 


SMITHSONIAN    MISCELLANEOUS   COLLECT 


VOL.    63,    NO.    1,    PL.    1 


Note:-  The  figures  in  Fran 
The  death  rate  for  I 


COMMONWEALTH  OF  PENNSYLVANIA 

DEPARTMENT  OF  HEALTH 

SAMUEL  G.  DIXON,  M.  D.,  COMMISSIONER 


^TV^T^JfiS^i  in  Franklin  County  include  the  deaths  at  the  State'Sanotoriunn  for  Tuberculosis  at  Mont  Alto,  numbering  2+8  >n  191?.! 
The  death  rate  for  Franklin  County  exclusive  of  Mont  Alto  would  be  118  ' 

Deoth3  per  100,000.      __ 
|     ~~\    0-49  ||||   100-149  ggZi  2°°  and  above 

^    50-99  §§§]    150"199 

MAP  SHOWING  DISTRIBUTION  OF  PULMONARY  TUBERCULOSIS  IN  PENNSYLVANIA  BY  COUNTIES  FOR  THE  YEAR  1912 


NO.    I  AIR    AND   TUBERCULOSIS — HINSDALE  3 

The  late  Dr.  Henry  I.  Bowditch,  of  Boston,  was  one  of  the  first 
physicians  in  America  to  recognize  the  value  of  constant  out-door 
life  in  the  treatment  of  tuberculosis  and  was  accustomed  to  send 
such  patients  on  easy  journeys  by  carriage  so  that  they  might  have 
the  benefit  of  as  much  out-door  air  as  possible,  becoming  gradually 
inured  to  the  elements. 

The  late  Dr.  Alfred  L.  Loomis,  of  New  York,  was  one  of  the  first 
to  systematically  send  tuberculous  patients  to  the  Adirondack  forest 
that  they  might  have  the  benefit  of  the  purest  and  most  invigorating 
air  obtainable  and,  like  the  physicians  of  ancient  Rome  who  sent 
consumptive  patients  to  the  pine  forests  of  Libya,  he  believed  that 
the  terebinthinate  exhalations  from  the  standing  pines  exerted  a  most 
beneficial  influence  on  pulmonary  affections.  Dr.  Loomis's  results 
were  so  gratifying  that  he  encouraged  Dr.  Edward  L.  Trudeau  to 
care  for  such  patients  in  the  Adirondack  Mountains  throughout 
the  year,  and  Dr.  Trudeau,  with  his  help,  founded  in  1884  the  first 
sanatorium  for  tuberculosis  in  America.1 

This  Adirondack  Cottage  Sanitarium,  now  in  its  thirtieth  year, 
has  been  the  inspiration  of  sanatoria  for  tuberculosis  throughout 
the  country.  Its  success  in  restoring  so  many  patients  to  health 
and  usefulness  is  not  wholly  estimated  in  figures.    It  has  established 


Cresson,  Cambria  Co. 

No.  of  patients  under  treatment 2>Z7 

Elevation  2,550  ft. 

Hamburg,  Berks  Co. 

In  the  course  of  construction  and  will  be  completed  some 
time  in  1914. 

Capacity   480 

Elevation    550  ft. 

These  institutions  care  for  both  incipient  and  far  advanced  cases.  The 
interior  arrangement  of  the  sanatoria  at  Cresson  and  Hamburg  is  such  that 
they  can  be  used  for  the  different  classes  of  cases  as  demand  may  necessitate. 
There  is  a  waiting  list  of  those  desiring  admission  to  these  institutions  at  all 
times. 

The  State  maintains  115  Tuberculosis  Dispensaries,  which  are  located 
throughout  the  67. counties  in  the  commonwealth.  There  are  220  physicians 
and  120  visiting  nurses  employed  in  these  dispensaries. 

By  the  courtesy  of  Dr.  Samuel  G.  Dixon,  Commissioner  of  Health,  we  are 
able  to  show  in  a  map  the  distribution  of  tuberculosis  in  the  counties  of  Penn- 
sylvania (pi.  1).  This  shows,  as  in  an  earlier  map  by  the  author,  that  the  dis- 
ease is  least  prevalent  in  the  higher,  forest  covered  regions  of  the  State. 

1  A.  L.  Loomis,  M.  D.  Evergreen  Forests  as  a  therapeutic  agent  in  pul- 
monary phthisis  (Trans.  Amer.  Climatological  Ass.,  Vol.  4,  1887).     See  page 

.134. 

2 


4  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

a  practical  method  of  cure  and  has  done  much  to  correct  the  earlier 
unfounded  and  mischievous  notions  that  prevailed  as  to  what  was 
necessary  for  the  cure  of  tuberculosis. 

Taking'  this  institution  as  an  example,  let  us  see  what  bearing  it 
may  have  on  our  general  subject,  the  relation  of  the  atmospheric  air 
to  tuberculosis : 

(a)  It  is  in  the  midst  of  an  evergreen  forest  of  over  10,000  square 
miles ;  (b)  the  atmosphere  is  pure,  or  at  least  as  pure  as  may  be  ob- 
tained on  the  continent;  (c)  the  air  is  moderately  moist;  (d)  the 
rainfall  averages  35  inches;  (e)  the  air  is  moderately  rarefied,  ow- 
ing to  (f)  an  elevation  of  1,750  feet;  (g)  owing  to  its  northern 
situation  (latitude  440)  and  its  elevation  (1,750  feet)  (h)  the 
climate  is  cold  in  winter  and  (i)  subject  to  rather  sudden  changes 
with  an  annual  range  of  590  C.  or  1380  F. 

CHAPTER    II.     VALUE    OF    FORESTS,    MICRO-ORGANISMS, 
ATMOSPHERIC  IMPURITIES 

GENERAL    BENEFIT    OF    FORESTS 

It  has  come  to  be  an  axiom  in  phthisiology  that  the  air  of  an 
evergreen  forest  is  eminently  suitable  for  a  patient  with  tuberculo- 
sis.1 As  we  have  previously  mentioned,  the  pine  forests  of  Libya 
were  used  two  thousand  years  ago  for  the  cure  of  "ulcerated  lungs." 
At  that  period  the  pines  abounded  and  gave  the  locality  a  reputation 
as  a  health  resort  for  affections  of  the  lungs.  But  the  ravages  of 
time,  aided  by  fire  and  sword,  not  to  speak  of  domestic  needs,  have 
obliterated  all  vestiges  of  these  ancient  forests. 

The  successful  institutions  located  in  the  Hartz  Mountains,  the 
Black  forest  of  Germany,  in  the  Forest  of  Ardennes,  the  State 
Forest  Reserve  of  Pennsylvania,  and  the  Adirondack  Forest  in  New 
York  owe  much  of  their  success  to  the  abundant  use  of  the  purest 
air  both  day  and  night. 

European  Governments  have  long  recognized  the  great  value  of 


1  The  following  quotation  from  Pliny  shows  that  it  was  generally  agreed 
in  his  day  that  the  forests  and  especially  those  which  abound  in  pitch  and 
balsam  are  the  most  beneficial  to  consumptives  or  those  who  do  not  gather 
strength  after  long  illness,  and  that  they  are  of  more  value  than  the  voyage 
to  Egypt: 

"  Sylvas,  eas  duntaxat  quae  picis  resinaeque  gratia  redantur,  utilissimas 
esse  phthisicis,  aut  qui  longa  aegritudine  non  recolligant  vires,  satis  constat; 
et  ilium  coeli  aera  plus  ita  quam  navigationem  Aegyptiam  proficere,  plus  quam 
lactis  herbidos  per  montium  aestiva  potus." — C.  Plinii,  Hist.  Nat.  lib.  xxiv, 
Cap.  6. 


H   " 


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O  =>  5 

<    W     £ 

>   COD 

Ul    -> 

-i  r.   >> 

Ml    r-    .S3 


13 

til    UJ 

O   x 

HK 

CO   z 
UJ    — 


NO.    I  AIR    AND   TUBERCULOSIS — HINSDALE  5 

their  forests  and  have  protected  them  by  strictly  enforcing  intelligent 
laws  so  that  they  may  be  forever  preserved  and  improved.  The  his- 
tory of  forestry  in  the  United  States  and  Canada  has  been  that  of 
ruthless,  unrestrained,  wholesale  destruction  of  nearly  all  our 
standing  pine,  and  heavier  spruce.  In  recent  years,  however,  we  have 
seen  the  establishment  of  Government  reserves,  State  reserves,  and 
State  laws  for  their  protection ;  the  organization  of  the  American 
Forestry  Association,  the  American  Forest  Congress,  the  Society 
for  the  Preservation  of  the  Adirondack  Forest ;  the  Schools  of  For- 
estry at  Yale,  Harvard  University  and  Mont  Alto,  Penna.  All  these 
remedial  measures  have  come  very  late,  but  will  undoubtedly  exert 
a  strong  influence  for  good.1 

Aside  from  the  generally  beneficial  influence  of  forests,  universally 
recognized  by  climatologists,  these  natural  parks  have  proved  the 
means  of  restoring  thousands  of  persons  suffering  from  tuberculosis 
and  diseases  of  the  respiratory  system. 

QUALITIES   OF   FOREST   AIR   AND   SOIL 

The  qualities  of  forest  air  and  forest  soil  have  been  studied  by 
E.  Ebermayer 2  who  shows  that,  like  that  of  the  sea  and  mountains, 
forest  air  is  freer  from  injurious  gases,  dust  particles,  and  bacteria. 
It  was  shown  that  the  vegetable  components  of  the  forest  soil  contain 
less  nutritive  matter  (albuminoid,  potash,  and  phosphates  and  ni- 
trates) for  bacterial  growth ;  that  the  temperature  and  moisture 
conditions  are  less  favorable ;  that  the  sour  humus  of  the  forest 
soil  is  antagonistic  to  pathogenic  bacteria ;  finally  that,  so  far,  no 
pathogenic  microbes  have  ever  been  found  in  forest  soil ;  hence  this 
soil  may  be  called  hygienically  pure. 

The  soil  is  protected  from  high  winds  by  forest  growth  and  under- 
growth ;  the  upper  soil  strata  are  slow  to  dry  out  and  wind  sweeping 
over  them  carries  few  micro-organisms  into  the  air.  As  may  be 
expected,  fewer  microbes  are  found  in  forest  air  than  outside  their 
limits.     Serafini  and  Arata  have  proved  this  experimentally.3    They 


1  The  chief  forester  of  the  United  States  has  in  1913  under  his  care  in  160 
forest  reservations  a  total  of  165,000,000  acres  of  forest  land.  The  present 
Chief  Forester  has  done  excellent  work  in  the  prevention  of  serious  forest 
fires. 

2E.  Ebermayer:  (1)  Hygienic  significance  of  forest  air  and  forest  soil. 
(2)  Experiments  regarding  the  significance  of  humus  as  a  soil  constituent; 
and  influence  of  forest,  different  soils,  and  soil-covers  on  composition  of  air 
in  the  soil.    Wollny,  1890  (Hygeia,  August,  15,  1891). 

3  Serafini  and  Arata :  Intorno  all  'azione  dei  boschi  sui  mikro  organismi 
transportati  dai  venti. 


6  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

exposed  plates  in  the  forest  air  and  on  its  outskirts  and  tabulated 
their  countings  of  bacteria  for  forty  successive  days  from  May  6. 
They  made  three  classes — molds,  liquefying-  and  non-liquefying 
bacteria.  They  found  that,  with  one  exception,  one  or  two  of  these 
classes  were  always  less  numerous  in  the  forest  than  on  its  outskirts 
and  generally  from  twenty-three  to  twenty-eight  times  less.  Serafini 
makes  the  point  that  bacteria  coming  from  the  outside  are  reduced  in 
number  by  a  sort  of  filtration  process.  Thus  we  see  that  the  air  of 
forests  is  comparatively  free  from  endogenous  and  exogenous  bac- 
teria— none  of  them  in  any  case  being  pathogenic.1 

CARBON   DIOXIDE  IN    FORESTS 

Puchner  shows  that  the  air  in  the  forest  contains  generally  more 
carbonic  acid  gas  than  in  the  open,  due  to  the  decomposition  of 
litter.2  But  this  difference  must  be  almost  inappreciable.  As  we 
know,  the  law  of  diffusion  of  gases  renders  it  impossible  for  varia- 
tions in  the  relative  proportion  of  the  atmospheric  constituents  to  be 
more  than  transitory.  Diffusion  is  greatly  favored  by  the  winds 
which  sweep  through  the  tree  tops,  especially  where  they  are  not 
too  crowded. 

The  fact  that  so  many  sanatoria  for  tuberculosis  are  located  in  or 
near  forests  makes  it  very  important  to  dwell  a  little  longer  on  the 
constituents  of  the  air  in  these  localities.  We  know  that  forests, 
as  well  as  all  other  forms  of  vegetal  growth,  take  up  large  quantities 
of  carbonic  acid,  retaining  the  carbon  and  rejecting  the  oxygen, 
and  the  question  naturally  arises,  does  it  sensibly  change  the  relative 
quality  of  either  constituent  so  that  the  composition  of  the  air  is 
slightly  different  in  the  woods?  Prof.  Mark  W.  Harrington,  lately 
chief  of  the  United  States  Weather  Bureau,  undertook  to  answer 
that  question,  both  with  reference  to  carbonic  acid,  oxygen,  and 
ozone,  with  some  interesting  results.8  Repeated  observations  show 
that  each  constituent  is  curiously  uniform  in  quantity  in  the  free 
air.  It  has  been  thought  that  carbonic  acid  is  quite  variable  but 
the  introduction  of  better  methods  of  observation  shows  that,  except 
in  confined  places  where  the  gas  is  produced,  the  variations  are  very 


1  See  B.  E.  Fernow :    Forest  Influences,  U.  S.  Dep.  Agriculture,  Forestry 
Division  Bulletin  No.   7,  pp.   171-173. 

2  H.  Puchner :    Investigations  of  the  Carbonic  Acid  Contents  of  the  Atmos- 
phere. 

\M.  W.  Harrington:    Review  of  Forest  Meteorological  Observations,  U. 
S.  Dep.  Agriculture,  Forestry  Division  Bulletin  No.  7,  p.  105. 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    5 


DR.  WALTHER'S  SANATORIUM,    NORDRACH-COLONIE,    BLACK   FOREST,   GERMANY 


VIEW   FROM   THE  ADIRONDACK  COTTAGE  SANITARIUM 

In  the  foreground  are  the  pines  and   my  only   business  in   life  is  to  sit  and   look  at  them  " 

Courtesy  of  Journal   of  The  Outdoor  Life 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  7 

small.  A  little  study  shows  that  the  carbonic  acid  gas  taken  up  by 
a  forest  is  a  very  small  quantity  compared  with  that  which  passes 
the  forest  in  the  same  time  with  the  moving  air.  Grandeau  1  esti- 
mated the  annual  product  of  carbon  by  a  forest  of  beeches,  spruces, 
or  pines  as  about  2,700  pounds  per  acre.  This  corresponds  to  9,900 
pounds  of  carbonic  acid  gas  or  69,300  cubic  feet.  Now,  if  the  aver- 
age motion  of  the  air  is  five  miles  an  hour,  a  low  estimate,  and  the 
layer  of  air  from  which  the  gas  is  taken  be  estimated  at  one  hundred 
feet  thick,  there  would  pass  over  an  acre  550  million  cubic  feet  in 
one  hour.  This  air  must  contain  about  three  parts  in  ten  thousand 
of  carbonic  acid  gas  and  the  total  amount  of  the  latter  per  hour  is 
165,000  cubic  feet.  But  this  is  two  and  two-thirds,  or  more  than 
twice  as  much  as  that  taken  up  by  the  trees  in  the  entire  season, 
so  that  the  air  could  provide  in  thirty  minutes  for  the  wants  of  the 
trees  for  the  entire  season.  Prof.  Harrington  shows  that  the  ratio 
of  carbonic  acid  used  to  that  furnished  is  only  one  part  in  8,600. 

OXYGEN   IN    FORESTS 

Again,  the  additions  of  oxygen  to  the  air  would  form  a  still 
smaller  percentage  of  the  oxygen  already  present,  for  this  gas  makes 
up  20.938  per  cent  of  the  air  against  a  thirtieth  of  one  per  cent  ob- 
tainable from  this  source. 

OZONE   IN    FORESTS 

The  occurrence  of  ozone  in  the  air  of  forests,  especially  coniferous 
forests,  has  been  credited,  since  its  discovery  by  Schoenbein  in  1840, 
with  affording  remarkable  health-giving  qualities.  This  opinion  has 
become  firmly  fixed  in  the  minds  of  the  public  and,  to  a  large  extent, 
has  been  accepted  by  the  medical  profession  as  an  evidence  of  high 
oxidizing  power  at  once  corrective  of  decaying  vegetation  and  exhil- 
arating and  curative  to  mankind.  Popular  belief  usually  has  some 
basis  for  its  existence ;  indeed,  meteorologists  made  regular  estima- 
tions of  ozone  in  the  atmosphere  by  testing  with  sensitized  papers 
and  the  results  were  published  in  connection  with  statistics  of  health 
resorts.2 

The  Schonbein  test  is  based  on  the  power  of  ozone  to  free  iodine 
from  a  solution  of  potassium  iodide  in  contact  with  starch,  when  a 
violet  color  is  developed  in  the  sensitized  paper.  Unfortunately  the 


aSee  Belgique  Horticole,  Vol.  35,   1885,  p.  227. 

2  See  Transactions  American  Climatological  Association,  Vol.  5,  p.  118. 


8  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

discovery  of  important  sources  of  error  has  destroyed  the  value  of 
observations  made  in  this  manner.  Other  substances  in  the  air 
have  been  found  to  act  as  reducing  agents ;  secondly,  the  color  after 
having  appeared  may  be  altered  or  destroyed  by  substances,  such  as 
sulphurous  acid  and  many  organic  substances.  Again,  the  test  acts 
only  in  a  moist  atmosphere  and,  besides  that,  varies  in  intensity 
according  to  the  amount  of  the  wind,  so  that,  in  a  way,  it  is  a 
measure  of  humidity  and  of  wind. 

A  more  recent  test,  mentioned  by  Huggard  as  more  sensitive, 
depends  upon  the  use  of  what  is  known  as  tetra-paper,  but  is  also 
considered  uncertain.  The  full  name  of  this  reagent  is  tetramethyl- 
paraphenylendiamin  paper.  Notwithstanding  the  unsatisfactory  na- 
ture of  these  tests,  the  conclusion  seems  to  be  accepted  that  ozone  is 
more  abundant  in  May  and  June  and  least  abundant  in  December 
and  January ;  more  abundant  in  the  forests  and  the  seashore  and  in 
mid-ocean  and  least  abundant  in  towns  where  it  commonly  cannot  be 
detected.  The  following  quotation  is  from  page  332  et  seq.  of  Vol. 
1,  Watts'  Dictionary  of  Chemistry: 

Very  little  is  known  respecting  the  proportion  of  ozone  in  the  atmosphere, 
or  of  the  circumstances  which  influence  its  production.  The  ozonometric 
methods  hitherto  devised  are  incapable  of  affording  accurate  quantitative 
estimations.  Air  over  marshes  or  in  places  infested  by  malaria  contains  little 
or  no  ozone.     No  ozone  can  be  detected  in  towns  or  in  inhabited  houses. 

Houzeau  determines  the  relative  amount  of  ozone  in  the  air  by  exposing 
strips  of  red  litmus  paper  dipped  to  half  their  length  in  a  1  per  cent  solution 
of  potassium  iodide.  The  paper  in  contact  with  ozone  acquires  a  blue  colour 
from  the  action  of  the  liberated  potash  upon  the  red  litmus.  The  iodised 
litmus  paper  is  preferable  to  iodised  starch  paper  (Schonbein's  test-paper) 
which  exhibits  a  blue  coloration  with  any  reagent  which  liberates  iodine, 
e.  g.,  nitrous  acid,  chlorine,  etc.  From  observations  made  with  iodised  litmus 
paper  Houzeau  concludes  that  ozone  exists  in  the  air  normally,  but  the  inten- 
sity with  which  it  acts  at  any  given  point  of  the  atmosphere  is  very  variable. 
Country  air  contains  at  most  ^^Voif  0I  lis  weight  or  yooVoo  of  its  volume  of 
ozone.  The  frequency  of  the  ozone  manifestations  varies  with  the  seasons, 
being  greatest  in  the  spring,  strong  in  summer,  weaker  in  autumn,  and  weakest 
in  winter.  The  maximum  of  ozone  is  found  in  May  and  June,  and  the  mini- 
mum in  December  and  January.  In  general,  ozone  is  more  frequently  ob- 
served on  rainy  days  than  in  fine  weather.  Strong  atmospheric  disturbances, 
as  thunder  storms,  gales,  and  hurricanes,  are  frequently  accompanied  by  great 
manifestations  of  ozone.  According  to  Houzeau,  atmospheric  electricity 
appears  to  be  the  most  active  cause  of  the  formation  of  atmospheric  ozone. 

It  has  been  found  that  the  air  immediately  above  the  tree  tops 
and  at  the  margin  of  the  forest  is  richer  in  ozone  than  that  of  the 
interior,  where  a  portion  of  it  is  utilized  by  the  decaying  vegetation. 
Ozone  certainly  aids  in  purifying  the  air  by  oxidizing  animal  or 


o  S 


3    -1 


NO.    I  AIR    AND   TUBERCULOSIS — HINSDALE  9 

vegetable  matter  in  process  of  decay  and  by  uniting  with  the  gases 
produced  by  their  decomposition.  It  can,  therefore,  be  found  in  con- 
siderable amounts  where  the  air  is  particularly  pure.  This  amount 
rarely  exceeds  one  part  in  10,000.  "  There  is  somewhat  more  ozone 
on  mountains  than  on  plains  and  most  of  all  near  the  sea.  Water  is 
said  by  Carius  to  absorb  0.8  of  its  volume  of  ozone."  * 

This  statement  by  Mr.  Russell  seems  to  us  extraordinary  in  view 
of  the  minute  quantity  contained  in  the  atmosphere  and  apparently 
needs  confirmation,  especially  in  view  of  Russell's  next  statement 
that  a  great  excess  of  ozone  is  destructive  to  life,  and  oxygen  con- 
taining one  two-hundred  and  fortieth  part  of  ozone  is  rapidly  fatal, 
and  further,  that  even  the  ordinary  quantity  has  bad  effects  in 
exacerbating  bronchitis  and  bronchial  colds,  and  some  other  affec- 
tions of  the  lungs. 

Ozone  is  not  found  in  the  streets  of  large  towns  or  usually  in 
inhabited  rooms,  but  in  very  large,  well-ventilated  rooms  it  is  some- 
times, though  rarely,  detected.  According  to  Russell  it  may  be 
formed  by  the  slow  oxidation  -of  phosphorus  and  of  essential  oils 
in  the  presence  of  moisture.  When  produced  by  electric  discharges 
its  pungency  of  odor  is  said  to  make  it  easily  perceptible  when  pres- 
ent only  to  the  extent  of  one  volume  in  2,500,000  volumes  of  air 
and  the  smell  may  sometimes  be  noticed  on  the  sea  beach. 

Since  the  discovery  of  ozone  by  Schonbein,  not  much  has  been 
learned  about  the  actual  origin  of  this  allotropic  form  of  oxygen. 
Its  presence  in  and  near  forests  and  living  plants  has  undoubtedly 
supported  the  popular  view  that  the  air  of  forests  is  particularly 
healthful  and  that  living  plants  in  our  apartments  are  likewise  bene- 
ficial.2 

The  existence  of  hydrogen  peroxide  in  air  was  first  established  by  Meissner 
in  1863,  but  we  have  no  knowledge  of  the  proportion  in  which  it  is  present. 
All  information  as  to  its  relative  distribution  is  obtained  from  determinations 
of  its  amount  in  rain  water  and  snow.  The  proportion  seems  to  vary,  like  that 
of  ozone,  with  the  seasons  of  the  year  and  with  the  temperature  of  the  air. 
It  is  not  improbable  that  the  amount  of  hydrogen  peroxide  in  air  is  greater 
than  that  of  ozone,  and  it  is  possible  that  many  so-called  ozone  manifestations 
are  in  reality  due  to  peroxide  of  hydrogen.    Watts'  Dictionary  of  Chemistry. 


1  Francis  A.  R.  Russell :  The  Atmosphere  in  Relation  to  Human  Life  and 
Health,  Smithsonian  Miscellaneous  Collections,  Vol.  39  (Publication  No. 
1072),    148  p.,  Washington,   1896. 

2  See  J.  M.  Anders :    House  Plants  as  Sanitary  Agents,  Lippincott  &  Co., 


10  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

A  recent  paper  by  Sawyer,  Beckwith  and  Skolfield 1  of  the  Hygi- 
enic Laboratory  of  the  California  State  Board  of  Health,  is  one  of 
the  latest  researches  which  discredit  the  claim  made  for  ozone  as  a 
purifier  of  air.  During  recent  years  circulars  have  been  issued  in 
great  numbers  by  manufacturers  of  apparatus  stating  that  ozone 
is  a  "  necessity  "  for  the  destruction  of  infectious  germs  and  bac- 
terial life,  for  the  sterilization  of  air  in  operating  rooms  for  the 
purification  of  air  in  homes  of  persons  suffering  from  contagious 
diseases  and  for  giving  to  offices  and  homes  the  invigorating  air  of 
the  country,  seashore  and  mountains.2 

How  false  these  claims  are  can  readily  be  seen  from  the  systematic 
work  of  these  investigators,  the  details  of  which  we  cannot  give 
here  but  to  which  the  reader  is  referred.  Among  their  conclusions 
are  the  following: 

During  these  tests  certain  physiologic  effects  of  the  "  ozone  "  were  noticed 
by  the  experimenters  after  they  had  been  working  around  the  machines. 
The  immediate  effect  of  inhaling  the  diluted  gas  was  a  feeling  of  dryness 
or  tickling  in  the  nasopharynx,  and  sometimes  the  irritation  was  felt  in  the 
chest.  If  the  exposure  was  prolonged,  watering  of  the  eyes,  and  occasionally 
a  slight  headache,  resulted.  The  smell  of  the  "  ozone  "  and  its  irritation  was 
much  more  noticeable  to  persons  who  came  suddenly  under  its  influence  than 
to  those  who  were  continuously  exposed. 

1.  The  gaseous  products  of  the  two  well-known  ozone  machines  examined 
are  irritating  to  the  respiratory  tract  and,  in  considerable  concentration,  they 
will  produce  edema  of  the  lungs  and  death  in  guinea-pigs. 

2.  A  concentration  of  the  gaseous  products  sufficiently  high  to  kill  typhoid 
bacilli,  staphylococci  and  streptococci,  dried  on  glass  rods,  in  the  course  of 
several  hours,  will  kill  guinea-pigs  in  a  shorter  time.  Therefore  these 
products  have  no  value  as  bactericides  in  breathable  air. 

3.  Because  the  products  of  the  ozone  machines  are  irritating  to  the  mucous 
membranes  and  are  probably  injurious  in  other  ways,  the  machines  should 
not  be  allowed  in  schools,  offices  or  other  places  in  which  people  remain  for 
considerable  periods  of  time. 

4.  The  ozone  machines  produce  gases  which  mask  disagreeable  odors  of 
moderate  strength.  In  this  way  the  machines  can  conceal  faults  in  ventilation 
while  not  correcting  them.  Because  the  ozone  machine  covers  unhygienic 
conditions  in  the  air  and  at  the  same  time  produces  new  injurious  substances, 
it  cannot  properly  be  classed  as  a  hygienic  device. 

Another  paper  even  more  elaborate  than  this  was  published  at 
the  same  time  by  Edwin  O.  Jordan,  Ph.  D.,  and  A.  J.  Carlson,  Ph.  D., 


xThe  Alleged  Purification  of  Air  by  the  Ozone  Machine.     Journ.  Amer. 
Med.  Ass.,  Sept.  27,  1913,  p.  1013. 
2  See  Amer.  Journ.  Physiologic  Therapeutics,  Nov.-Dec,  191 1. 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  II 

of  Chicago.1  This  investigation  was  carried  on  at  the  suggestion  of 
and  under  a  grant  from  the  Journal  of  the  American  Medical  Asso- 
ciation. Their  experiments  were  carried  out  (i)  to  determine  the 
germicidal  action  of  ozone  on  pure  cultures  under  the  conditions 
commonly  used  in  testing  disinfectants,  and  (2)  to  determine  the 
effect  of  ozone  on  the  ordinary  air  bacteria.  They  found,  after  a 
long  series  of  experiments  detailed  in  full  in  their  paper,  that  no 
surely  germicidal  action  on  certain  species  of  bacteria  could  be 
demonstrated  by  the  usual  disinfection  tests  with  amounts  of  gaseous 
ozone  ranging  from  3  to  4.6  parts  per  million.  The  alleged  effect  of 
ozone  on  the  ordinary  air  bacteria,  if  it  occurs  at  all,  is  slight  and 
irregular  even  when  amounts  of  ozone  far  beyond  the  limit  of  phy- 
siologic tolerance  are  employed.2  The  toxication  of  strong  concen- 
trations of  ozone  through  injury  to  the  lungs  was  marked.  Even 
in  moderate  amounts  it  produced  an  irritation  of  the  sensory  nerve 
endings  of  the  throat  and  a  headache  due  to  irritation,  corrosion 
and  consequent  hyperemia  of  the  frontal  sinuses.  Consequently  the 
use  of  this  poisonous  gas  as  a  therapeutic  agent  is  either  valueless 
or  injurious. 

USE  OF   FOREST   RESERVATIONS   FOR   SANATORIA 

We  cannot  leave  the  subjects  of  forests  and  forest  air  without 
strongly  advocating  the  use  of  forests  and  especially  State  and 
Governmental  forest  reserves  for  institutions,  hospitals,  and  camps 
for  the  tuberculous.  The  State  of  Pennsylvania  has  large  forestry 
reservations,  amounting  at  present  to  1,000  square  miles  in  23  coun- 
ties, and  maintains  a  State  School  of  Forestry,  where  young  men  are 
in  training  for  its  forest  service.  Acting  under  liberal  forest  laws, 
Dr.  J.  T.  Rothrock,  then  State  Forestry  Commissioner,  in  1903,  an- 
nounced that  citizens  of  Pennsylvania  are  entitled  to  the  privilege 
of  using  the  forestry  reservation  of  the  state  under  proper  restric- 
tions as  a  residence  while  regaining  health  and  recommended  it  espe- 
cially to  those  in  need  of  fresh  air  treatment  of  tuberculosis.  In 
the  spring  of  that  year  Dr.  Rothrock,  with  State  aid,  started  the 
construction  of  a  few  small  cabins  for  the  use  of  such  patients  and 
called  it  the  South  Mountain  Camp  Sanatorium.3    This  is  situated 


1  Ozone :     Its   Bactericidal   Physiologic  and  Deodorizing  Action.      ( Journ. 
Amer.  Med.  Ass.,  Sept.  27,  1913,  Vol.  61,  pp.  1007-1012). 

2  This  is  corroborated  by  the  recent  article  by  Konrich,  Zur  Verwendung 
der  Ozone  in  der  Liiftung.     (Zeitschr.  Hyg.,  1913,  Vol.  73,  443-) 

3  Charities  and  Commonwealth,  Dec.  1,  1906.    Journ.  Amer.  Med.  Ass.,  1907. 
Journal  of  the  Outdoor  Life,  Jan.,  1907,  and  Feb.,  1908. 

3 


12  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

in  Franklin  County,  Pennsylvania,  in  the  southern  tier  of  counties 
where  the  state  owns  55,000  acres.  The  altitude  of  the  camp  is 
1,650  to  1,700  feet.  It  is  now  the  site  of  the  great  State  Sanatorium 
known  as  Mont  Alto  with  a  capacity  of  over  1,000  patients. 

At  first  the  patients  were  obliged  to  provide  and  to  prepare  their 
own  food,  but  the  legislature  afterward  appropriated  enough  to 
enable  the  management  to  furnish  food,  and  the  results  were  better 
than  before.  Only  patients  in  the  incipient  stages  were  admitted, 
and  of  the  141  so  cared  for  (up  to  the  year  1908)  about  75  per 
cent  were  either  much  improved  or  cured.  The  charge  to  the  patients 
was  one  dollar  per  week  for  all  supplies  and  services,  excepting 
washing  and  the  care  of  their  cabins  and  their  persons.  The  large 
forestry  reserve  allows  of  an  indefinite  extension  of  this  method  of 
dealing  with  the  disease,  and  the  small  expense  seems  to  point  to  it 
as  a  way  to  provide  for  the  large  class  of  patients  who  must  be  cared 
for  in  the  incipient  stages  if  the  disease  is  to  be  checked  and  its 
victims  restored  to  society  as  safe  and  potent  factors  in  industrial 
progress.  Dr.  Rothrock,  who  has  just  closed  twenty  years  of  distin- 
guished service  to  the  state  in  the  forestry  commission,  believes 
that  the  forest  reservations  furnish  an  answer  to  the  further  prob- 
lem of  how  to  care  for  the  consumptive  whose  disease  is  arrested, 
but  whose  financial  condition  demands  that  he  must  still  be  cared  for 
until  able  to  return  to  his  home.  Pennsylvania  has  nearly  a  million 
acres  of  forest  reservation,  much  of  which  needs  replanting  with 
young  trees.  To  do  this  requires  a  large  number  of  men,  and  the 
task  of  raising  and  transplanting  trees  is  mostly  light  outdoor  labor, 
well  suited  to  the  convalescent  consumptive.  In  addition,  there  are 
various  forms  of  woodcraft,  such  as  basket  making  and  the  manu- 
facture of  small  rustic  articles  that  could  easily  be  carried  on  under 
healthful  conditions  in  the  forests.  The  example  of  Pennsylvania 
suggests  the  propriety  of  other  states  taking  similar  steps  and  pro- 
viding for  the  large  number  of  consumptives  who  need  care  in  an 
inexpensive  and  at  the  same  time  effective  manner. 

The  United  States  Government  should  establish  without  delay 
large  forest  reserves  in  the  Eastern,  Middle,  and  Southern  States. 
The  White  Mountains  of  New  Hampshire  and  the  Southern  Appa- 
lachians should  be  placed  under  a  system  of  Federal  protection.  It 
is  encouraging  to  note  that  by  a  recent  decision  (November,  191 3) 
of  the  Courts  of  New  Hampshire  the  way  is  opened  for  the  condem- 
nation of  mountain  land  in  that  State  and  indemnity  has  been 
awarded  private  owners  for  land  so  taken. 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  13 

The  United  States  has  165,000,000  acres  of  national  forests  and 
France  and  Germany  combined,  14,500,000  acres. 

The  site  of  a  model  sanatorium  for  tuberculosis  has  the  purest 
air  or  air  nearly  devoid  of  floating  matter.  It  is  only  on  very  high 
mountain  tops  or  in  mid  ocean,  or  in  the  Polar  ice  fields  that  we 
can  have  air  free  from  suspended  matter.  The  good  results  obtained 
in  the  higher  Alpine  sanatoria  and  in  long  sea  voyages,  in  given 
cases  of  tuberculosis,  are  attributable  in  some  degree  to  this  absence 
of  irritating  or  polluted  atmosphere.  In  the  more  northern  sanatoria, 
of  which  the  Adirondack  Cottage  Sanitarium  is  a  type,  the  long 
winter  in  which  snow  covers  the  ground  for  possibly  five 
months,  is  always  recognized  as  the  best  season  for  patients.  The 
gain  in  health  acquired  during  one  winter  equals  that  of  two  sum- 
mers. The  added  freedom  which  the  snow  covering  provides  against 
dust  and  other  atmospheric  impurities  may  have  its  hygienic  influ- 
ence for  the  cure  of  tuberculosis. 

MICRO-ORGANISMS    IN    RESPIRATORY    PASSAGES 

It  is  interesting  to  learn  something  of  the  fate  of  micro-organisms 
when  inhaled  by  a  person  in  health  or  by  those  whose  respiratory 
passages  are  already  suffering  from  irritation  or  disease.  It  has  been 
calculated  that  upward  of  14,000  organisms  pass  into  the  nasal  cavi- 
ties in  one  hour's  quiet  respiration  in  the  ordinary  London  atmos- 
phere.1 Tyndall  showed  by  his  experiments  with  a  ray  of  light 
in  a  dark  chamber  that  expired  air,  or  more  exactly  the  last  portion 
of  the  air  of  expiration  is  optically  pure.  In  other  words,  respiration 
has  freed  the  inhaled  air  from  the  particles  of  suspended  matter 
with  which  it  is  laden.  These  experiments  coincide  with  those  of 
Gunning  of  Amsterdam  in  1882  and  those  of  Strauss  and  Dubreuil 
in  1887.  Grancher  has  made  many  experiments  with  the  expired  air 
of  phthisical  patients  and  has  never  found  in  it  the  tubercle  bacillus 
or  its  spores.  Charrin,  Karth,  Cadeac,  and  Mallet  have  had  corre- 
sponding results. 

These  germs  are  probably  all  arrested  before  reaching  the  trachea  ; 
they  halt  in  the  upper  air  passages.  The  interior  of  the  great  majority 
of  normal  nasal  cavities  is  perfectly  aseptic.  On  the  other  hand 
the  vestibules  of  the  nares,  the  vibrissa;  lining  them  and  all  crusts 
formed  there  are  generally  swarming  with  bacteria.  All  germs  are 
arrested  here  and  the  ciliated  epithelium  rapidly  ejects  them. 


aOn  Researches  by  Drs.   St.  Clair  Thomson  and  R.  T.  Hewlet.     Lancet, 
January   11,    1896. 


14  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

By  experiments  on  the  mucous  membrane  of  the  dorsal  wall  of  the 
pharynx,  Thomson  and  Hewlet  found  that  a  particle  of  wet  cork  was 
conveyed  at  the  rate  of  25  mm.  or  one  inch  per  minute. 

Wurtz  and  Lermoyez  have  published  researches  on  the  action  of 
nasal  mucus  upon  the  anthrax  bacillus  and  they  hold  that  it  exerts 
a  bactericidal  influence  on  all  or  nearly  all  pathogenic  agents  in  dif- 
ferent degrees  of  intensity. 

Thomson  and  Hewlet  corroborate  this  to  the  extent  of  saying 
that  the  nasal  mucus  "  is  possessed  of  the  important  property  of 
exerting  an  inhibitory  action  on  the  growth  of  micro-organisms." 
Their  experiments  upon  each  other  were  very  ingenious  and  highly 
interesting.  They  were  able  to  demonstrate  that  in  ordinary  air  of 
the  laboratory  under  the  conditions  observed,  29  moulds  and  nine 
bacterial  colonies  developed  ;  whereas  after  passing  through  the  nose 
the  air  contained  only  two  moulds  and  no  bacteria. 

On  another  occasion  they  found  in  nine  liters  of  laboratory  air, 
six  moulds  and  four  bacterial  colonies,  while  the  same  quantity  of 
air  after  passing  through  the  nose  exhibited  one  mould  and  no  bac- 
teria. Thus  they  show  that  practically  all,  or  nearly  all,  the  micro- 
organisms of  the  air  are  arrested  before  reaching  the  naso-pharynx ; 
probably  a  majority  are  stopped  by  the  vibrissas  at  the  very  entrance 
to  the  nose  and  those  which  do  penetrate  as  far  as  the  mucous 
membrane  are  rapidly  eliminated.  They  state  that  the  nasal  mucus 
is  an  unfavorable  soil  for  the  growth  of  organisms  and  in  this  it  is 
aided  by  the  ciliated  epithelium  and  lacrymal  secretion.. 

COMPOSITION    OF    EXPIRED    AIR 

Dr.  D.  H.  Bergey  in  1893-4  made  some  experiments  in  the  Labor- 
atory of  Hygiene  of  the  University  of  Pennsylvania  under  the  pro- 
visions of  the  Hodgkins  Fund  of  the  Smithsonian  Institution  which 
are  pertinent  to  this  subject.1  These  were  conducted  to  ascertain 
whether  the  condensed  moisture  of  air  expired  by  men  in  ordinary, 
quiet  respiration,  contains  any  particulate  organic  matters,  such  as 
micro-organisms,  epithelial  scales,  etc.  The  expired  breath  was  con- 
ducted through  melted  gelatin  contained  in  a  half  liter  Erlenmayer 
flask,  for  twenty  to  thirty  minutes.    The  gelatin  was  then  hardened 


1J.  S.  Billings,  S.  Weir  Mitchell,  and  D.  H.  Bergey:  The  Composition  of 
Expired  Air  and  Its  Effects  on  Animal  Life.  Smithsonian  Contributions  to 
Knowledge,  Vol.  29  (Publication  989),  Washington,  1895.  This  investigation 
seemed  to  disprove  the  renowned  experiments  of  Brown-Sequard  and  D'Ar- 
sonval  in  1887. 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  15 

by  rolling  the  flask  in  a  shallow  basin  of  ice- water,  thus  distributing 
the  culture  in  a  thin  layer  over  the  bottom  and  sides  of  the  flask. 

These  cultures  were  kept  under  observation  for  20  to  30  days. 
About  150  cc.  of  gelatin  was  used  for  each  experiment.  The  glass 
tube  (b)  of  the  apparatus  used,  which  served  for  the  entrance  of  the 
expired  air,  was  inserted  far  enough  to  just  impinge  on  the  fluid 
culture  medium  in  the  flask,  so  that  the  air  produced  a  slight  agita- 
tion of  the  fluid  in  passing  through  the  apparatus.  The  tube  of 
entrance  (b)  is  provided  with  a  bulb-shaped  enlargement  which 
serves  to  retain  any  saliva  that  may  flow  into  the  tube.  The  tube 
(c)  is  closed  with  cotton  so  as  to  prevent  the  entrance  of  micro- 
organisms from  this  side  of  the  apparatus,  and  a  similar  cotton  plug 
is  inserted  in  b  when  the  apparatus  is  not  in  use. 


Apparatus  for  Determining  the  Presence  of  Bacteria  in  Expired  Breath. 

It  was  found  that  the  organisms  developed  in  the  cultures  were 
all  of  the  same  character — a  small  yellow  bacillus,  common  in  labora- 
tory air.  When  special  precautions  were  taken  to  sterilize  the  appa- 
ratus with  dry  heat  for  an  hour  previous  to  introducing  the  gelatin, 
besides  the  subsequent  sterilization  of  the  gelatin,  the  results  were 
negative — no  growths  developed.  If,  after  standing  in  the  working 
room  for  several  days,  it  was  found  that  the  culture  medium  was 
sterile,  the  expired  breath  was  then  conducted  through  the  apparatus 
and  the  culture  was  kept  under  observation  (for  the  specified  time 
in  the  table)  at  the  room  temperature.  The  nature  of  the  organisms 
that  developed  in  the  first  two  experiments,  and  the  absence  of  any 
growth  in  the  others,  make  it  probable  that  they  developed  from 
spores  that  survived  the  fractional  sterilization  of  the  culture  me- 
dium. It  is  improbable  that  they  were  carried  in  the  expired  breath. 
Dr.  Bergey  also  made  a  careful  examination  of  the  fluid  condensed 
from  the  expired  air  with  high  powers,  both  in  hanging  drops  and  in 
six  dried  and  stained  preparations,  but  nothing  resembling  bacteria 
or  epithelium  was  found. 

The  conclusion  was  reached  that  there  is  no  evidence  of  a  special 


l6  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

toxicity  of  the  expired  air.  Billings,  Mitchell,  and  Bergey  say,  in 
the  monograph  referred  to,  that  the  injurious  effects  of  such  air  ob- 
served appeared  to  be  due  entirely  to  the  diminution  of  oxygen,  or 
the  increase  of  carbonic  acid,  or  to  a  combination  of  these  two  fac- 
tors. They  consider  that  the  principal,  though  not  the  only,  causes  • 
of  discomfort  to  people  in  crowded  rooms  are  excessive  temperature 
and  unpleasant  odors. 

We  shall  see,  further  on,  that  later  studies  show  that  the  relative 
proportions  of  oxygen  and  carbonic  acid  are  not  per  se  such  impor- 
tant factors. 

Dr.  Milton  J.  Rosenau,  professor  of  preventive  medicine  and 
hygiene  in  Harvard  Medical  School,  said  in  his  recent  address1  on 
"  Ether  Day  "  at  the  Massachusetts  General  Hospital : 

One  of  the  fallacies  that  has  fallen  is  the  relation  of  the  air  to  the  spread  of 
infection.  The  virus  of  most  communicable  diseases  was  believed  to  be  in 
the  expired  breath,  or  exhaled  as  emanations  of  some  sort  from  the  body. 
These  emanations  were  said  to  be  carried  long  distances — miles — on  the  wind. 
The  easiest,  and  therefore  the  most  natural  way,  to  account  for  the  spread 
of  epidemic  diseases  was  to  consider  them  as  air-borne.  Nowadays  the  sani- 
tarian pays  little  heed  to  infection  in  the  air  except  in  droplet  infection,  and 
the  radius  of  danger  in  the  fine  spray  from  the  mouth  and  nose  in  coughing, 
sneezing  and  talking  is  limited  to  a  few  feet  or  yards  at  most.  The  more 
the  air  is  studied  the  more  it  is  acquitted  as  a  vehicle  for  the  spread  of  the 
communicable  diseases. 

It  was  a  great  surprise  when  bacteriologists  demonstrated  that  the  expired 
breath  ordinarily  contains  no  bacteria.  Most  micro-organisms,  even  if  wafted 
into  the  air  soon  die  on  account  of  the  dryness,  and  especially  if  exposed  to 
sunshine.  The  relation  of  the  air  to  infection  is  nowhere  better  illustrated 
than  in  the  practice  of  surgery.  At  first  Lister  and  his  followers  attempted 
to  disinfect  the  air  in  contact  with  the  wound  by  carbolic  sprays.  Now  the 
surgeon  pays  no  heed  to  the  air  of  a  clean  operating  room,  but  ties  a  piece 
of  gauze  over  his  mouth  and  nose,  and  also  over  his  hair,  to  prevent  infective 
agents   from   falling  into  the  wound   from  these  sources. 

How  complicated  this  entire  subject  is  we  can  readily  see  from  the 
review 2  made  by  Dr.  Henry  Sewall,  of  Denver,  of  recent  experimen- 
tal studies  by  Zuntz,  Haldane,  Rosenau  and  Amoss,  Heymann,  Paul, 
Ercklentz  and  Fliigge,  Leonard  Hill  and  others.  This  review  de- 
serves to  be  read  carefully.  It  sums  up  our  latest  knowledge  and 
leads  to  some  surprising  conclusions.  After  describing  the  Black 
Hole  of  Calcutta,  in  which  one  hundred  and  forty-six  Europeans 


1  Boston  Medical  and   Surgical  Journal,  November  6,   1913. 

2  On  What  do  the  Hygiene  and  Therapeutic  Virtues  of  the  Open  Air  De- 
pend? by  Henry  Sewall,  Ph.  D.,  M.  D.  (Journ.  Amer.  Med.  Ass.,  Jan.  20, 
1912). 


NO.    I  AIR  AND  TUBERCULOSIS HINSDALE  1 7 

were  confined  on  the  night  of  June,  1756,  and  only  twenty-three 
survived,  he  shows  that  numberless  observations  have  all  led  to  the 
one  conclusion  that  prolonged  confinement  in  close  air  tends  to  lower 
vitality  and  increase  the  incidence  of  certain  infections,  especially  pul- 
monary tuberculosis.  However,  it  was  found  many  years  ago  that 
animals  and  men  can  tolerate  without  distress  an  increase  of  car- 
bon dioxide  in  the  air  far  beyond  any  concentration  which  it  is  likely 
to  acquire  under  the  worst  conditions  of  crowding,  provided  the 
oxygen  tension  is  maintained  at  a  high  level.  Zuntz  and  Haldane 
and  his  associates  show  that  the  normal  excitement  of  the  respiratory 
nerve-center  depends  on  the  accumulation  within  it  of  carbon  diox- 
ide, a  waste  product,  which  it  is  a  prime  object  of  respiration  to 
remove.  Sewall  refers  to  Brown-Sequard  and  D'Arsonval's  work 
and,  as  bearing  on  it,  the  very  recent  work  of  Rosenau  and  Amoss.1 
These  workers  condensed  the  vapor  of  human  expiration  and  in- 
jected the  liquid  into  guinea-pigs.  No  symptoms  followed  this  pro- 
cedure. But  after  an  appropriate  interval  of  some  weeks  a  little 
of  the  blood-serum  from  the  person  supplying  the  moisture  was 
injected  into  the  same  animals.  The  outcome  was  an  unmistakable 
anaphylactic  reaction.  According  to  current  beliefs  the  result  showed 
that  the  expired  air  must  have  contained  proteid  matter  which  sensi- 
tized the  pigs  toward  proteids  in  the  blood  of  persons  from  whom 
the  first  proteid  was  derived.  The  authors  offer,  as  yet,  no  opinion 
as  to  whether  the  proteid  in  the  expired  air  possesses  hygienic 
significance. 

Prof.  Sewall  finds  a  suggestive  analogy  in  the  physiologic  rela- 
tions of  carbon  dioxide  which  it  is  one  of  the  chief  objects  of 
respiration  to  remove.  Added  to  air  in  sufficient  percentage  it  is 
deadly  to  animals,  yet  so  far  from  its  being  useless  in  the  body,  Hal- 
dane and  Priestley  found  that  it  must  form  four  to  five  per  cent  of 
the  alveolar  air  for  the  maintenance  of  normal  respiratory  move- 
ment, and  a  considerable  lowering  of  its  tension  in  the  body  would 
be  followed  by  speedy  death.  Boycott  and  Haldane  note  that  the 
subjective  sense  of  invigoration  and  well-being  excited  by  cold 
weather  is  associated  with  a  high  tension  of  carbon  dioxide  in  the 
alveolar  air.2    After  summarizing  the  experiments  of  Heyman,  Paul, 


Organic  Matter  in  the  Expired  Breath  (Journal  of  Medical  Research,  1911, 
Vol.  25,  35). 

2  Haldane  and  Priestley:  The  Regulation  of  the  Lung  Ventilation  (Journal 
of  Physiology,   1905,  Vol.  27,  p.  225). 

Boycott  and  Haldane :  The  Effects  of  Low  Atmospheric  Pressure  on  Respi- 


l8  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

and  Ercklentz  in  Fliigge's  laboratory1  which  seem  to  show  that, 
in  people  both  well  and  sick,  chemical  changes  in  the  character  of  the 
air  in  inhabited  rooms  exercise  no  deleterious  effect  on  the  health  of 
the  dwellers  Dr.  Sewall  reviews  Leonard  Hill's  work  which  shows 
that  the  motion  of  the  air  in  the  experimental  chamber  by  means 
of  electric  fans  almost  entirely  annulled  the  sense  of  discomfort.2 
He  then  cites  the  astonishing  experiments  of  F.  G.  Benedict  and 
R.  D.  Milner3  who  kept  a  subject  for  twenty-four  hours  in  a  cham- 
ber, the  air  of  which  held  an  average  carbon  dioxide  content  of  220 
parts  per  10,000  or  over  seventy  times  the  normal,  together  with  a  re- 
duction of  oxygen  to  less  than  19  per  cent.  The  humidity  was  kept 
down  and  the  temperature  held  uniform.  The  subject  of  the  experi- 
ment suffered  no  discomfort. 

Boycott  and  Haldane,  referred  to  above,  express  the  opinion  that 
"  the  alveolar  carbon  dioxide  tends  to  a  lower  level  in  warm 
weather  "  and  that  this  diminution  in  the  alveolar  carbon  dioxide 
is  associated  with  a  feeling  of  warmth  of  a  rather  unpleasant  kind 
rather  than  with  any  absolute  point  on  the  thermometer ;  they  hold 
that  the  rise  in  the  carbon  dioxide  tension  is  associated  with  the 
general  exhilaration  and  stimulation  produced  by  cold  air. 

And  now  comes  Leonard  Hill,  the  physiologist,  of  London,  who 
with  his  staff  at  the  London  Hospital  conducted  several  noteworthy 
experiments  which  he  described  before  the  Institution  of  Heating 
and  Ventilating  Engineers  in  March,  191 1.4    In  view  of  the  fact  that 


ration  (Journal  of  Physiology,  1908,  Vol.  37,  p.  359).  See  also  Preventive 
Medicine  and  Hygiene,  by  Milton  J.  Rosenau,  M.  D.,  Chapter  4,  D.  Appleton 
&  Co.,  1913.  Prof.  Rosenau's  work  contains  the  latest  word  on  the  bacteria 
and   poisonous   gases   in  the   air,  ventilation,    etc. 

Thomas  R.  Crowder,  M.  D. :  A  Study  of  the  Ventilation  of  Sleeping  Cars 
(Archives  of  Internal  Medicine,  January,  1911,  and  January,  1913).  This 
elaborate  investigation  is  illustrated  by  numerous  diagrams  showing  the 
carbon  dioxide  content  in  the  air  from  the  aisles,  the  upper  and  lower 
berths  and  smoking  rooms. 

1  Zeitschrift  f.  Hygien.  u.  Infectionskr.,  1905,  Vol.  59. 

"  Leonard  Hill :  The  Relative  Influence  of  Heat  and  Chemical  Impurity 
of    Close  Air    (Journal  of    Physiology,    1910,   Vol.   41,    p.   3). 

See  also  Leonard  Hill,  Martin  Flack,  James  Mcintosh,  R.  A.  Rowlands, 
H.  B.  Walker :  The  Influence  of  the  Atmosphere  on  our  Health  and  Com- 
fort in  Confined  and  Crowded  Places,  Smithsonian  Miscellaneous  Collections, 
Vol.  60,  No.  23,  p.  96  (Publication  2170),  1913. 

3  Experiments  on  the  Metabolism  of  Matter  and  Energy  in  the  Human 
Body,  Bulletin  175,  U.  S.  Dep.  Agriculture  Office  Experiment  Station,  1907. 

*Journ.   Amer.  Med.  Ass.,   April  8,   191 1. 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  IO, 

the  London  health  authorities  insist  that  in  factories  the  percentage 
of  carbon  dioxide  must  not  rise  above  the  usual  amount  allowed, 
say  ten  parts  in  ten  thousand,  he  remarks  that  the  regulations  do  not 
prescribe  any  limitations  of  the  wet-bulb  temperature  adding  that 
while  carbon  dioxide  does  not  do  any  harm  whatever  a  wet-bulb 
temperature  of  75°  F.  is  very  bad  and  ought  not  to  be  tolerated  in 
any  factory.  All  the  current  teaching  of  the  hygiene  of  ventilation 
runs  on  the  subject  of  chemical  purity  of  the  air;  but  according 
to  Prof.  Hill  the  essential  thing  in  ventilation  is  heat,  not  chemical 
purity.  It  does  not  matter  if  there  is  I  per  cent  more  carbon  dioxide 
and  i  per  cent  less  of  oxygen.  In  the  worst  ventilated  rooms  there 
is  not  i  per  cent  less  oxygen.  The  only  effect  of  an  excess  of  car- 
bon dioxide  is  to  make  one  breathe  a  little  more  deeply.  A  much 
higher  amount  has  to  be  attained  to  have  any  toxic  effect.  As  to 
organic  impurities  derived  from  respiration  there  is  no  physiologic 
evidence  of  their  toxicity  or  that  they  are  of  any  importance  ex- 
cept as  an  indicator  of  the  number  of  bacteria  in  air.  The  way  to 
keep  air  best  from  the  physiologic  point  of  view  is  shown  by  the 
following  experiment  performed  by  Hill  at  the  London  Hospital: 
Into  a  small  chamber  which  holds  about  three  cubic  meters  he  put 
eight  students  and  sealed  them  up  air  tight.  They  entered  joking 
and  lively  and  at  the  end  of  44  minutes  the  wet  bulb  temperature 
had  risen  to  83 °  F.  They  had  ceased  to  laugh  and  joke  and  the  dry 
bulb  stood  at  87  °  F.  They  were  wet  with  sweat  and  their  faces 
were  congested.  The  carbon  dioxide  had  risen  to  5.26  per  cent  and 
the  oxygen  had  fallen  to  15.1  per  cent.  Hill  then  put  on  three  elec- 
tric fans  and  merely  whirled  the  air  about  just  as  it  was.  The 
effect  was  like  magic ;  the  students  at  once  felt  perfectly  comfortable, 
but  as  soon  as  the  fans  stopped  they  felt  as  bad  as  ever  and  they 
cried  out  for  the  fans.  These  and  other  experiments  related,  accord- 
ing to  Hill,  show  that  all  the  discomfort  from  breathing  air  in  a  con- 
fined space  is  due  to  heat  and  moisture  and  not  to  carbon  dioxide. 
Even  after  five  repetitions  of  the  experiment  there  were  no  after- 
effects, such  as  headache.  The  obvious  inference  is  that  the  air 
must  be  kept  in  motion  to  avoid  bad  effects.  The  open  air  treat- 
ment of  disease  is  not  altogether  a  matter  of  fresh  air,  but  the 
constant  cooling  of  the  body  by  the  circulation  of  air  which  makes 
us  eat  more  and  promotes  activity.  This  leads  to  the  general 
strengthening  of  the  body  because  the  blood  is  not  only  circulated 
by  the  heart  but  by  every  muscle  in  the  body. 

There  cannot  be  efficient  circulation  without  constant  movement 


20  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

and  activity.    If  there  is  constant  cooling  by  ventilation,  then  a  per- 
son is  kept  more  active  and  the  general  health  is  improved. 
As  Dr.  M.  J.  Rosenau  said  in  his  recent  address  : 

Thus  our  entire  conception  of  ventilation  has  changed,  owing  to  the  fact 
that  we  now  do  not  believe  that  fresh  air  is  particularly  necessary  in  order 
to  furnish  us  with  more  oxygen  or  to  remove  the  slight  excess  of  carbon 
dioxide.  It  is  plain  that  it  is  heat  stagnation  that  makes  us  feel  so  uncom- 
fortable in  a  poorly  ventilated  room  rather  than  any  change  in  the  chemical 
composition  of  the  air.  It  has  been  made  perfectly  clear  from  the  work 
of  Fliigge  that  one  of  the  chief  functions  of  fresh  air  is  to  help  our  heat-regu- 
lating mechanism  maintain  the  normal  temperature  of  the  body.  It  is 
necessary  to  have  some  2,000  to  3,000  cubic  feet  of  air  an  hour  to  maintain 
our  thermic  equilibrium — just  the  amount  that  was  formerly  stated  to  be 
necessary  to  dilute  the  carbon  dioxide  and  supply  fresh  oxygen.  The  prac- 
tice of  ventilation,  therefore,  has  not  altered  so  much  as  has  our  reason  for 
attaching  importance  to  clean,  cool,  moving  air,  which  has  completely  changed.1 

The  foregoing  resume  is  perhaps  not  complete  without  mentioning 
the  recent  work  of  Prof.  Yandell  Henderson,  of  Yale  University, 
who  has  brought  forward  his  "Acapnia"  theory  (acapnia  meaning 
diminished  carbon  dioxide  in  the  blood) .     He  says  :2 

We  have  really  at  the  present  time  no  adequate  scientific  explanation  for 
the  health-stimulating  properties  of  fresh  air  and  the  health-destroying  influ- 
ence of  bad  ventilation.  .  .  .  The  subject  needs  investigating  along  new  lines 
rather  than  a  rehearsal  of   old  data. 

Dr.  Crowder's  recent  experiments  s  also  furnish  additional  evidence 
against  the  theory  that  efficient  ventilation  consists  in  the  chemical 
purity  of  the  air,  in  its  freedom  from  "  a  toxic  organic  substance." 
Even  were  a  poisonous  protein  substance  present  in  the  expired  air 
— a  fact  no  experimenter  has  yet  been  able  to  demonstrate — the 
human  organism  under  every-day  conditions  is  apparently  well  able 
to  adjust  itself  to  the  reinhalation  of  this  hypothetic  substance,  since 
a  considerable  quantity  of  the  expired  air  is  always  taken  back  into 
the  lungs.4 

We  consider  that  experiments  like  these  demonstrate  most  valu- 
able and  practical  truths  and  that  is  our  excuse  for  introducing 
them  so  particularly  in  this  place.  When  we  consider  that  the  aver- 
age man  exhales  from  9,000  to  10,800  liters  of  air  in  twenty-four 


1  Boston  Medical  and  Surgical  Journal,  Nov.  6,  1913. 

2  Trans.    Fifteenth    International   Congress   on   Hygiene   and   Demography, 
Vol.  7,  p.  622. 

3  Crowder,  Thomas  R. :   The  Reinspiration  of  Expired  Air  (Arch.  Int.  Med., 
October,    1913,   p.   420). 

4  Editorial  in  Journ.  Amer.  Med.  Ass.,  Nov.  29,  1913.    See  also  page  10S. 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  21 

hours '  it  would  indeed  be  a  terrible  situation  if  it  were  true  that 
the  expired  breath  could  convey  pathogenic  or  other  bacilli.  The 
millions  of  bacilli  which  we  take  into  the  air  passages  are  arrested 
in  the  air  passages  and  for  the  most  part  mercifully  destroyed  by 
the  secretion.2  In  any  event  we  have  the  assurance  that  the  expired 
air  is  free  from  micro-organisms.  With  reference  to  tuberculosis 
this  means  that  if  healthy  persons  are  exposed  only  to  the  expired  air 
of  tuberculous  subjects  no  infection  can  occur.  Only  through  bacilli 
contained  in  the  sputum  or  in  tiny  drops  of  moisture  coughed  by 
the  patient  is  the  disease  communicated ;  and  it  is  further  probable 
that,  as  in  the  case  of  other  infectious  organisms,  when  once  re- 
ceived into  the  nose  and  mouth  and  upper  air  passages,  they  quickly 
lose  their  activity  or  are  soon  extruded.    (See  page  13  et  seq.) 

ATMOSPHERIC   IMPURITIES 

In  view  of  these  facts  it  would  scarcely  seem  necessary  to  state 
that  for  the  treatment  of  all  respiratory  diseases  and  especially 
for  the  treatment  of  infections  such  as  tuberculosis,  which  invades 
the  larynx  and  the  lungs,  or  for  the  treatment  of  patients  whose 
throats  and  lungs  owing  to  other  infections,  such  as  tonsillitis, 
pneumonia,  or  influenza,  may  be  specially  susceptible,  no  city  air  can 
be  considered  favorable.  It  is  our  duty  to  provide  as  nearly  as  possi- 
ble air  with  a  very  low  bacterial  content  such  as  may  be  obtained  in 
forests  or  in  the  neighborhood  of  the  seashore. 

COAL  AND  SMOKE 

Aside  from  the  presence  of  bacteria  in  the  air  of  cities  and  towns 
there  are  other  impurities  which  are  of  great  disadvantage  to  tubercu- 
lous patients.  The  prevalent  use  of  soft,  or  bituminous  coal  in  Great 
Britain  and  America,  especially  in  manufacturing  centers,  undoubt- 
edly shortens  human  life  and  hastens  many  a  consumptive  to  his  end. 
Volumes  have  been  written  on  this  subject  and  most  valuable  contri- 
butions have  been  made  by  Dr.  J.  B.  Cohen,  of  Leeds,  Mr.  Francis 
A.  R.  Russell,  Henry  de  Varigny  and  others,  published  in  connection 
with  the  Hodgkins  Fund.3 

'About  380  cubic  feet  which  is  equal  to  a  volume  7^  feet  (220  cm.)  in 
height,   width,   and  thickness. 

2  It  has  been  calculated  that  in  a  town  like  London  or  Manchester,  a  man 
breathes  in  during  ten  hours  37,500,000  spores  and  germs.    F.  A.  R.  Russell. 

3  See  Smithsonian  Miscellaneous  Collections,  Vol.  39,  1896  (Publications 
1071,  1072,  1073). 

See  also  "  The  Influence  of  Smoke  on  Acute  and  Chronic  Lung  Infections," 
by  Wm.  Charles  White,  M.  D.,  and  Paul  Shuey,  Pittsburg.  Trans.  Amer. 
Climatological  .Association,    1913. 


22  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

Dr.  William  Charles  White  and  Paul  Shuey,  of  Pittsburgh,  have 
recently  made  a  study  of  the  influence  of  smoke  on  acute  and  chronic 
lung  infections,  selecting  pneumonia  and  tuberculosis  as  a  cause  of 
death  in  Pittsburgh,  St.  Louis,  Portland,  Oregon,  St.  Paul,  Cincin- 
nati, Chicago,  Philadelphia,  New  York,  New  Orleans,  Richmond, 
Cleveland,  San  Francisco,  Indianapolis,  Minneapolis,  Memphis,  Bos- 
ton, Mobile,  and  Los  Angeles.  They  plotted  the  number  of  smoky 
days  per  year,  1907  to  1912,  with  the  smokiest  cities  first  and  so  on 
to  the  least  in  the  order  indicated  above.  The  mortality  for  white 
population  and  total  population  and  other  data  are  noted  on  the  ac- 
companying chart.  This  study  is  in  some  respects  unsatisfactory, 
because  of  the  difficulty  of  getting  data  as  to  smoky  days.  The  con- 
clusion was  that  if  we  except  Portland  and  St.  Paul  there  is  a 
general  tendency  of  the  tuberculosis  death  rate  to  rise  as  the  number 
of  smoky  days  in  the  city  decreases.  On  the  other  hand,  it  will  be 
seen  that  there  is  a  general  tendency  for  the  number  of  deaths  from 
pneumonia  to  fall  as  the  number  of  smoky  days  in  the  city  decreases. 
In  this  instance,  also,  Portland,  St.  Paul,  and  Boston  must  be  ex- 
cepted.    All  this  needs  confirmation. 

It  is  a  matter  of  common  knowledge  that  coal  miners  are  liable 
to  a  disease  called  fibrosis,  anthracosis,  or  miners'  consumption,  in 
which  the  lungs  receive  and  retain  coal  dust,  which  penetrates  every 
nook  and  cranny  of  the  lungs  and  adds  one  more  element  of  danger 
to  a  most  hazardous  occupation.  But  we  have  it  on  the  authority  of 
Sir  Frederick  Treves  that  he  had  seen  the  lungs  of  many  persons, 
who  had  lived  in  London,  which  were  black  from  their  surface  to 
their  innermost  recesses.  Such  a  condition,  in  his  opinion,  not  only 
made  it  more  difficult  to  resist  disease,  but  started  disease,  and  it  was 
entirely  due  to  dirt  and  soot  inhaled.  The  black  fog  of  London  owes 
its  color  to  coal  smoke,  which  gives  it  its  filthy,  choking  constituents, 
and  kills  people  by  thousands.  Experiments  showed  that  during 
a  bad  fog  six  tons  of  soot  were  deposited  to  the  square  mile.1 


1  Some  six  hundred  years  ago,  the  citizens  of  London  petitioned  King  Ed- 
ward I  to  prohibit  the  use  of  "  sea  coal."  He  replied  by  making  its  use 
punishable  by  death.  This  stringent  measure  was  repealed,  however,  but 
there  was  again  considerable  complaint  in  Queen  Elizabeth's  reign,  and  the 
nuisance  created  by  coal  smoke  seems  to  have  been  definitely  recognized 
at  this  period.  Since  this  time  there  has  been  continual  agitation,  together 
with  much  legislation,  both  abroad  and  in  this  country.  In  the  seventeenth 
century,  King  Charles  II  adopted  repressive  measures  in  London,  and  in  the 
present  century  anti-smoke  crusades  have  been  frequent.  In  fact,  the  smoke 
problem   will    undoubtedly   continue  to   demand   attention   until   it   is    either 


NO.    I 


AIR    AND   TUBERCULOSIS — HINSDALE 


23 


24  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

The  Lancet  undertook  by  means  of  a  system  of  gauges  of  its  own 
design  to  estimate  the  annual  deposit  in  London  of  all  adventitious 
matter  from  the  atmosphere.  In  the  city  proper  it  was  calculated 
to  be  nearly  five  hundred  tons  to  the  square  mile  or  about  four  and  a 
half  pounds  per  acre  each  day.  Were  it  mere  dirt  it  would  not  be  so 
serious,  but  it  is  charged  with  gases  and  fluids  of  a  deleterious  char- 
acter such  as  sulphates,  chlorides,  ammonia,  and  carbon  that  is  more 
or  less  oily  and  tarry.  One  of  the  experts  employed  by  the  Meteoro- 
logical Council  in  connection  with  the  County  Council  of  London, 
found  that  the  sulphur  contents  of  the  coal  ranged  from  one  to  two 
per  cent  and  that  from  half  a  million  to  a  million  tons  of  sulphuric 
acid  were  diffused  in  the  air  every  year.  The  loss  to  property  from 
this  erosive  influence  he  estimated  at  about  five  and  a  half  million 
pounds  sterling.  The  effect  upon  health  was  a  more  elusive  question, 
but  stress  was  laid  on  the  rise  in  death  rate  during  foggy  weather 
in  which  coal  smoke  plays  a  prominent  part.  Owing  to  the  activity 
of  the  Coal  Smoke  Abatement  Society,  under  the  presidency  of  Sir 
William  Richmond,  atmospheric  conditions  are  greatly  improved, 
and  it  is  claimed  that  there  is  a  steady  diminution  in  the  number 
and  density  of  the  black  fogs. 

In  an  article  on  London  as  a  Health  Resort  and  as  a  Sanitary  City, 
by  S.  D.  Clippingdale,  M.  D.,  Trans.  Royal  Society  of  Medicine,  Feb- 
ruary, 1914,  there  is  an  interesting  historical  account  of  London  air 
and  fog,  with  a  bibliography. 

CARBON   DIOXIDE 

Parallel  conditions  are  observed  in  cities  like  Leeds,  Liverpool, 
Manchester,  and  Glasgow,  and  in  less  degree  in  cities  like  Pittsburgh, 
Cincinnati,  Chicago,  Cleveland,  and  St.  Louis,  during  periods  of 
comparatively  calm,  and  of  heavy  and  humid  atmosphere.  Egbert a 
states  that  "  it  has  been  calculated  that  for  every  ton  of  coal  burnt 
in  London  something  like  three  tons  of  carbon  dioxide  are  pro- 
duced," and  as  the  city's  coal  consumption  is  over  30,000  tons  per 
diem,  its  atmosphere  must  receive  the  enormous  daily  contamina- 
tion of  about  300  tons  of  soot  and  90,000  tons  of  carbonic  acid  every 
day!  How  important,  then,  the  adoption  of  practical  means  to 
abate  the  smoke  nuisance !     Engineers  assure  us  that  such  means 


entirely  solved  by  the  abolishment  of  the  use  of  solid  fuel  or  by  the  installa- 
tion, of  devices  and  methods  which  shall  prevent  the  formation  of  smoke  in 
furnaces,  regardless  of  the  nature  of  the  fuel. 

1  Seneca  Egbert :    A  Manual  of  Hygiene  and  Sanitation,  Philadelphia,  1900. 
P.   74- 


NO.    I  AIR    AND   TUBERCULOSIS — HINSDALE  25 

are  perfectly  feasible  and  economical.    It  does  not  need  an  engineer 
to  assure  us  that  they  are  hygienic. 

Prof.  Charles  Baskerville,  of  the  College  of  the  City  of  New  York, 
has  vigorously  attacked  the  problem  of  smoke  and  other  air  impuri- 
ties. He  shows  '  that  the  sticky  properties  of  soot  are  due  to  the  tar 
contained  in  it.  This  tar  adheres  so  tenaciously  to  everything  that  it 
is  not  easily  removed  by  rain.  In  large  manufacturing  districts,  par- 
ticularly in  those  where  bituminous  coal  is  used  as  fuel,  vegetation 
is  blackened,  the  leaves  of  trees  are  covered  and  the  stomata  are 
filled  up,  thus  inhibiting  the  natural  processes  of  transpiration  and 
assimilation.  In  addition,  the  soot  is  frequently  acid  and  the  deposi- 
tion of  acid  along  with  soot  is  probably  one  of  the  principal  causes 
of  the  early  withering  which  is  characteristic  of  the  many  forms  of 
town  vegetation. 

SULPHUR   DIOXIDE 

Aside  from  the  solid  material  which  pollutes  the  atmosphere  of 
cities,  there  are  correspondingly  enormous  quantities  of  noxious 
gases  which  are  equally  injurious  to  persons  with  tubercular  disease 
or  other  diseases  of  the  respiratory  tract.  Mention  has  already  been 
made  of  the  vast  amounts  of  carbonic  acid  gas  generated  by  fur- 
naces, not  to  speak  of  the  quantities  exhaled  by  human  beings.  The 
production  of  this  carbon  dioxide  by  the  combustion  of  coal  offers 
a  definite  measure  of  the  production  of  sulphur  dioxide.  These  two 
gases  have  the  same  origin  and  the  measure  of  one  is  the  measure 
of  the  other.  Recent  studies  by  Prof.  Theodore  W.  Schaefer,  who 
has  made  many  observations  of  the  air  of  Kansas  City  during  fogs, 
tend  to  show  that  the  presence  of  sulphur  dioxide  has  an  unfavorable 
effect  on  persons  suffering  from  bronchitis,  pharyngitis,  pneumonia, 
and  asthma.  In  January,  1902,  the  heavy  fogs  occurring  in  St. 
Louis,  Missouri,  caused  serious  injury  to  the  throat  and  lungs  of 
prominent  singers  and  in  an  action  brought  against  the  city  and  its 
chief  smoke  inspector,  it  was  alleged  that  owing  to  the  additional 
presence  of  smoke,  suffocating  gases,  and  acid,  the  health  of  the 
complainant  was  injured.  In  a  mandamus  proceeding  it  was  asked 
that  the  authorities  be  compelled  to  abate  the  smoke  nuisance. 

Prof.  Schaefer  has  used  the  data  mentioned  previously  as  to  the 
output  of  carbonic  acid  in  London  and  states  that  he  finds  that  at 
least  2,700  tons  of  sulphur  dioxide  are  generated  daily  in  that  city 
and  pass  into  surrounding  atmosphere.    This  gas,  after  uniting  with 


Medical   Record,   New  York,  November  23,  30,   1912. 


26  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

the  oxygen  and  aqueous  vapor  of  the  air,  is  converted  into  sulphuric 
acid.1 

The  presence  of  sulphur  in  coal,  or  in  iron  pyrites  contained  in 
coal,  is  responsible  for  this  acid  product  and  Prof.  Schaefer  believes 
that  sulphur  dioxide,  being  a  very  heavy  gas,  with  a  specific  gravity 
of  2.25,  is  alone  capable  of  creating  a  fog,  or  is  at  once  shown  when 
it  is  brought  in  contact  with  the  atmosphere,  from  which  it  absorbs 
aqueous  vapor,  causing  dense,  heavy  fumes.  The  dust  or  carbon 
particles,  coming  in  contact  with  this  acid  vapor,  enhance  its  grav- 
ity materially. 

Prof.  Baskerville  some  time  ago  made  a  number  of  determinations 
of  the  sulphur  dioxide  content  of  the  air  of  New  York  city.  Stations 
were  established  throughout  greater  New  York  city,  including  high 
office  buildings,  parks,  subways,  stations,  and  railroad  tunnels ;  and 
very  variable  results,  as  might  be  expected,  were  obtained.  The 
determinations  may,  in  part,  be  thus  summarized : 

Locality  SO2  in  parts  in  a  million 

Elevated    portion    of    city,    near    a 

high  stack  3.14 

Various   parks  0.84    (maximum;   others  negative) 

Railroad  tunnels  8. 54 — 31.50 

Subway  None 

Downtown   region  1.05 — 5.60 

Localities  near  a  railroad  1. 12— 8.40 

In  1907,  the  residents  of  Staten  Island,  as  well  as  some  on  Long 
Island,  complained  of  the  noxious  nature  of  the  air  wafted  over  from 
various  plants  in  New  Jersey.  This  induced  the  Department  of 
Health  of  the  City  of  New  York  to  investigate  the  air  and  vegetation 
in  the  vicinity  of  the  Borough  of  Richmond,  Staten  Island,  and 
some  of  the  results  obtained  are  given  below  by  permission  of  the 
Department. 

Substance  Impurity 

Air  Trace    of    sulphuric    acid 

Air  0.0066  per  cent.     S02  by  weight 

Air  Trace    of    sulphuric    acid 

Grass    (three  samples)                                Sulphuric   acid   present 

Grass  0.24  per  cent  S03 

Grass  0.70  per  cent  SO3 

Leaves  0.19  per  cent  S03 

Leaves  0.28  per  cent  SOs 

Soil  0.0015  per  cent  S03 

Theodore  W.  Schaefer:  The  Contamination  of  the  Air  of  our  Cities  with 
Sulphur  Dioxide,  the  Cause  of  Respiratory  Disease.  Boston  Medical  and 
Surgical  Journal,    July  25,    1907. 


NO.    I  AIR    AND   TUBERCULOSIS HINSDALE  27 

These  results  do  not  really  give  us  anything  definite,  as  the  com- 
parative factor  is  absent. 

Fog  usually  collects  in  the  lower  portions  of  a  city,  especially  in 
depressed  localities  known  as  hollows,  where  it  remains  until  dis- 
persed by  air  currents.  The  well-known  increase  of  mortality  in 
cities  during  the  continued  presence  of  heavy  fog  with  these  addi- 
tional contaminations  have  been  recorded  and  commented  upon  for 
years.  The  heavy,  suffocating,  poisonous  quality  of  sulphur  dioxide 
is  well  known  and  has  been  the  subject  of  several  investigations.  In 
general,  it  may  be  said  that  the  chief  symptoms  of  poisoning  with 
sulphurous  acid  are  those  of  irritation  of  the  mucous  membranes. 
Even  in  five  parts  in  10,000  it  acts  as  an  irritant,  causing  sneez- 
ing, coughing  and  lacrymation,  bronchial  irritation  and  catarrh 
(Cushny).  It  is  also  credited  with  causing  pneumonia  and  Prof. 
Schaefer  notes  its  power  to  produce  asthma.1  Undoubtedly  it  would 
aggravate  pulmonary  and  laryngeal  tuberculosis  and  either  delay 
or  prevent  a  cure  under  the  conditions  described. 

AMMONIA   IN    THE   AIR 

This  gas  is  constantly  present  in  the  atmosphere,  but  in  very 
minute  quantities.  Fifty  years  ago  Boussingault  and,  later,  Schloes- 
ing  made  careful  investigations  of  this  impurity  of  the  atmosphere 
and  devised  ingenious  methods  of  estimating  its  amount  in  air  and 
rain  water.  It  usually  exists  only  in  combination  with  carbonic 
or  nitric  acid;  very  little  is  free.  Water  absorbs  it  freely  and  it  has 
been  estimated  that  in  France  the  annual  rainfall  brings  to  the 
earth  in  the  form  of  nitrogen  nearly  5  kilograms  per  acre.  The 
presence  of  ammonia  indicates  organic  putrefaction.  Its  amount 
does  not  usually  exceed  a  very  few  parts  per  million.  It  is  usually 
perceptible,  as  we  all  know,  in  and  about  stables. 

As  far  as  any  relation  to  tuberculosis  is  concerned,  ammoniacal  air 
has  for  us  only  a  remote  interest.  At  one  time  it  was  strongly  advo- 
cated as  a  cure  for  pulmonary  consumption  and  perhaps  some  his- 
toric details  may  be  of  interest  here. 

Dr.  Thomas  Beddoes,  of  London,  published  in  1803,  "  Considera- 
tions on  a  Modified  Atmosphere  in  Consumption  Cases,"  and 
strongly  advocated  residence  in  a  cow  stable  for  such  cases.  One 
of  his  patients  was  Mrs.  Finch,  a  daughter  of  Dr.  Joseph  Priestley, 


1  This  accords  with  the  conclusions  of  W.  C.  White  and  Paul  Shuey,  loc.  cit. 
The  relation  of  Sea  Fog  to  Tuberculosis  is  considered  in  the  next  chapter, 
page  52. 


28  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

famous  for  his  epoch-making  discovery  of  Oxygen.  The  patient, 
from  the  description  given,  had  a  well-marked  case  of  pulmonary 
tuberculosis  in  the  second  or  third  stage.  She  was  placed  in  a  stable 
14  by  20  feet  and  9  feet  high,  and  her  bed  was  in  a  small  recess  a 
few  inches  above  the  ground  of  the  stable,  where  two  or  three  cows 
were  kept.  The  temperature  was  maintained  at  6o°  to  70  °  F.  Mrs. 
Finch  remained  in  this  cow  house  nearly  all  the  time  from  the 
autumn  of  1799  until  the  spring  of  1800.  In  a  letter,  dated  August 
15,  1800,  the  patient  wrote,  "  I  am  happy  in  being  able  to  say  that 
my  chest  continues  perfectly  well ;  and  from  the  difference  of  my 
feelings  now,  and  some  years  back,  I  am  more  than  ever  a  friend 
of  the  cows.  I  avoid  colds  and  night  air ;  and  by  rides  in  the  country 
am  anxious  to  brace  myself  against  winter  and  the  necessity  of  a 
sea  voyage." 

OXYGEN  FOR  TUBERCULOUS  PATIENTS 

Shortly  after  the  discovery  of  oxygen,  physicians  were  stimulated 
to  try  the  effect  of  various  gases  in  the  treatment  of  phthisis.  Four- 
croy  and  Beddoes  both  observed  the  effects  of  the  inhalation  of 
oxygen  and  found  that  it  accelerated  the  pulse  and  respiration,  and, 
as  they  believed,  increased  inflammatory  action  so  that  they  con- 
cluded that  its  effect  was  prejudicial.  Beddoes  held  that  in  phthisis 
there  is  an  excess  Of  oxygen  in  the  system  and  consequently,  that 
free  air  was  injurious  to  the  patient.  He  says  in  the  essay  quoted 
previously  :*  "  As  it  seemed  to  me  hopeless  to  propose  residence  in 
a  cow  house,  I  advised  that  the  patient  should  live  during  the  winter 
in  a  room  fitted  up  so  as  to  ensure  the  command  of  a  steady  tempera- 
ture. This  advice  was  followed.  Double  doors  and  double  windows 
were  added  to  the  bed  room.  The  fire  place  was  bricked  up  round 
the  flue  of  a  cast  iron  stove  for  giving  out  heated  air."  What  a  con- 
trast to  the  fresh  air  cure  of  the  present  day!  But  the  doctor  per- 
sisted in  his  plan  of  treatment  until  the  patient  died. 

The  amount  of  oxygen  present  in  the  atmosphere,  20.938  per  cent, 
is  precisely  adapted  to  the  needs  of  animal  life  and  the  same  propor- 
tion of  oxygen  is  preserved  in  the  atmosphere  everywhere,  without 
regard  to  altitude.2  It  has  been  found  that  animals  die  if  the  ratio 
of  oxygen  is  artificially  decreased  by  as  much  as  twenty-five  per 


1  Thomas  Beddoes :  Observations  on  the  Medical  and  Domestic  Manage- 
ment of  the  Consumptive.     American  edition,  Troy,  1803,  p.  42. 

2 Analyses  by  Gay-Lussac  of  Air  Collected  at  7,000  meters;  and  observa- 
tions by  Dumas  and  Boussingault. 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  20, 

cent ;  but  Paul  Bert *  also  showed  that  too  much  oxygen  was  equally 
prejudicial  to  life  and,  indeed,  poisonous,  animals  dying  in  a  super- 
oxygenated  atmosphere  as  soon  as  their  blood  contains  one-third 
more  than  the  normal  ratio  of  oxygen,  because  in  such  an  atmos- 
phere the  hemoglobin  of  the  red  blood  corpuscles  is  saturated  with 
oxygen— a  fact  which  never  occurs  under  normal  conditions — and  a 
proportion  of  this  gas  then  dissolves  in  the  serum  of  the  blood. 
Here  lies  the  danger,  for  the  tissues  cannot  withstand  the  presence 
of  free,  uncombined  oxygen  and  death  follows.  The  question  imme- 
diately arises:  Why  do  the  tissues  require  combined  oxygen  and 
why  does  free  oxygen  kill  them  ?.  No  one  knows.  Henry  de  Varigny, 
who  deals  with  this  subject  with  reference  to  aerobic  and  anaerobic 
organisms  deals  with  this  curious  fact  and  acknowledges  our  limited 
knowledge  on  this  point.  He  states,  however,  that  while  a  certain 
increase  in  the  ratio  of  oxygen  results  in  death,  lesser  increases  of 
a  temporary  character  may  be  beneficial.  Every  poison  kills,  doubt- 
less, but  there  are  doses  which  not  only  do  not  kill,  but  even  confer 
benefit  and  improve  health. 

Lorrain  Smith  has  shown  that  oxygen  at  the  tension  of  the  atmos- 
phere stimulates  the  lung-cells  to  active  absorption ;  at  a  higher 
tension  it  acts  as  an  irritant,  or  pathologic  stimulant,  and  produces 
inflammation.2 

As  far  as  the  respiratory  processes  are  concerned  the  respiration 
of  pure  oxygen  takes  place  without  disturbing  them  for  even  in  an 
atmosphere  of  pure  oxygen  animals  breathe  as  though  they  were 
respiring  normal  atmospheric  air/ 

Sir  Humphrey  Davy  believed  that  when  pure  oxygen  was  inspired 
there  is  no  more  chemical  change  induced  than  occurs  when  atmos- 
pheric air  is  breathed ;  in  other  words,  let  the  vital  actions  be  a 
constant  quantity,  the  addition  of  oxygen  to  the  inspired  air  does 
not  materially  increase  vital  transformation.  Fifty  years  ago  there 
was  great  confusion  in  the  minds  of  otherwise  intelligent  observers 
and  false  reasoning  led  them  into  grave  errors.  Those  who,  like 
Beddoes,  believed  that  there  was  too  much  oxygen  in  the  system  held 
that  the  inhalation  of  air  containing  carbonic  acid  was  the  proper 
plan  of  treatment  and  this  theory  of  hyper-oxidation  was  revived 


1  Paul  Bert :    La  Pression  Barometrique,  1878. 

See  also  monograph  by  F.  G.  Benedict  quoted  on  page  31. 

2  Lorrain  Smith,  in  Journal  of  Physiology,  1899,  Vol.  24,  p.  19. 

3  An  American  Text  Book  of  Physiology,  Vol.  1. 


30  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.   63, 

by  Baron  von  Liebig,  who  recommended  that  in  phthisis  the  respira- 
tory action  should  be  lessened.1 

The  Boston  Nutrition  Laboratory  of  the  Carnegie  Institution  of, 
Washington  has  undertaken  a  most  painstaking  series  of  investiga- 
tions bearing  on  this  subject.  They  include  an  examination  of  the 
comparative  oxygen-content  of  uncontaminated  outdoor  air  under 
all  conditions  as  to  wind  direction  and  strength,  temperature,  cloud 
formation,  barometer,  and  weather.  In  addition,  samples  of. air  were 
collected  on  the  Atlantic  Ocean,  on  the  top  of  Pike's  Peak,  in  the 
crowded  streets  of  Boston,  and  in  the  New  York  and  Boston  sub- 
ways. The  results  of  the  analyses  of  uncontaminated  outdoor  air 
showed  no  material  fluctuation  in  oxygen  percentage  in  observations 
extending  over  many  months  and  in  spite  of  all  possible  alterations 
in  weather  and  vegetative  conditions.  The  average  figures  are 
0.031  per  cent  of  carbon  dioxide  and  20.938  per  cent  oxygen.  The 
ocean  air  and  that  from  Pike's  Peak  gave  essentially  similar  results. 

The  extraordinary  rapidity  with  which  the  local  variations  in  the 
composition  of  the  air  are  equalized  is  accentuated  by  the  observa- 
tions on  street  air  in  the  heart  of  the  city,  where  the  contaminating 
factors  might  be  expected  to  be  of  sufficient  magnitude  to  affect 
perceptibly  the  analytic  data.  Only  the  slightest  trace  of  oxygen 
deficit  is  shown,  with  a  minute  corresponding  carbon-dioxide  incre- 
ment. Observations  such  as  these  tend  to  demonstrate  the  extent 
of  the  diffusion  of  gases  and  the  establishment  of  equilibrium  by  air- 
currents. 

Most  unexpected  are  the  figures  in  regard  to  the  extremely  small 
extent  to  which  the  air  was  vitiated  in  the  modern  "  tube  "  or  sub- 
way, even  during  "  rush "  hours.  There  was,  on  the  average,  a 
fall  of  0.03  per  cent  in  oxygen  accompanied  by  a  rise  of  0.032 
per  cent  in  the  carbon  dioxide.  Professor  Benedict  points  out  that 
while  the  measurement  of  carbon  dioxide  has  been  taken  as  an  index 
of  good  or  bad  ventilation,  the  fact  that  the  proportion  of  oxygen 
is  actually  lowered  by  an  increase  in  the  carbon  dioxide  has  never 
before  been  clearly  demonstrated.  As  a  result  of  this,  the  determina- 
tion of  the  content  of  carbon  dioxide  in  the  air,  which  can  be  made 
with  ease  and  accuracy,  suffices  to  establish  the  approximate  percent- 
age of  oxygen.  For  every  0.01  per  cent  increase  in  the  atmospheric 
carbon  dioxide  one  may  safely  assume  a  corresponding  decrease 
in  the  percentage  of  oxygen.     Aside  from  minor  fluctuations  ex- 


1  See    Edward    Smith :     Consumption,    Its    Early    and    Remediable    Stages. 
Blanchard    and   Lea,    Philadelphia,    1865. 


NO.    I  AIR    AND    TUBERCULOSIS HINSDALE  31 

plained  above,  it  may  now  truly  be  said  that  "  the  air  is  a  physical 
mixture  with  the  definiteness  of  composition  of  a  chemical  com- 
pound." 1 

Since  the  introduction '  into  medical  practice  of  oxygen  com- 
pressed in  cylinders  its  use  has  been  tried  in  tuberculous  cases,  but 
no  satisfactory  results  have  been  obtained  and  its  use  is  discontinued, 
except,  so  far  as  we  know,  in  the  hands  of  charlatans. 

The  inhalation  of  oxygen  gas  may  not  per  se  exert  any  curative 
action  on  a  tuberculous  lung,  but  that  fact  should  not  lead  us  to  the 
conclusion  that  the  voluntary  respiration  of  an  increased  quantity 
of  air  is  not  beneficial.  It  is  stated  that  the  air  in  the  central  parts 
of  the  lungs  is  richer  in  carbonic  acid  than  that  found  in  the  larger 
tubes  and  hence  deep  inspiration  followed  by  deep  expiration  causes 
a  larger  amount  of  the  air  richer  in  carbonic  acid,  to  be  exhaled. 
From  this  the  conclusion  is  drawn  that  increased  chemical  change 
will  result,  for  if  the  carbon  dioxide  be  removed  from  the  air  cells 
its  place  will  be  filled  by  quantities  of  the  same  gas  which  will  escape 
from  the  blood.  Furthermore,  the  removal  of  carbon  dioxide  from 
the  blood  facilitates  and  makes  possible  those  metabolic  changes 
which  with  a  supply  of  suitable  food  improve  nutrition. 

Nowadays  we  often  speak  of  oxygen  as  synonymous  with  atmos- 
pheric air  and  in  this  sense  we  give  it  a  prominent  place  in  pulmonary 
therapeutics.  We  are  tempted  to  reproduce  the  placard  of  an  old 
boot-maker  and  chiropodist  of  fifty  years  ago  which  read : 

The  best  medicine!  Two  miles  of  oxygen  three  times  a  day.  This  is  not 
only  the  best,  but  cheap  and  pleasant  to  take.  It  suits  all  ages  and  con- 
stitutions. It  is  patented  by  Infinite  Wisdom,  sealed  with  a  signet  divine. 
It  cures  cold  feet,  hot  heads,  pale  faces,  feeble  lungs  and  bad  tempers. 
If  two  or  three  take  it  together  it  has  a  still  more  striking  effect.  It  has  often 
been  known  to  reconcile  enemies,  settle  matrimonial  quarrels  and  bring 
reluctant  parties  to  a  state  of  double  blessedness.  This  medicine  never  fails. 
Spurious  compounds  are  found  in  large  towns ;  but  get  into  the  country 
lanes,  among  green  fields,  or  on  the  mountain  top,  and  you  have  it  in  perfec- 
tion as  prepared  in  the  great  laboratory  of  nature. 

Before  taking  this  medicine  .  .  .  should  be  consulted  on  the  understanding 
that   corns,   bunions,   or  bad  nails,   prevent  its  proper  effects. 


1  See  the  recent  monograph  by  Benedict,  F.  G. :  The  Composition  of  the 
Atmosphere  with  Special  Reference  to  Its  Oxygen  Content,  Carnegie  Insti- 
tution of  Washington,  Publication  166,  1912.  Review  in  Journ.  Amer.  Med. 
Ass.,  Jan.  25,   1913. 

2  The  late  Dr.  Andrew  H.  Smith,  of  'New  York,  was  the  first  in  the  United 
States  to  use  Oxygen  in  medical  practice,  i860.  "  Oxygen  gas  as  a  Remedy  in 
Disease,"    A.   H.    Smith,    1870. 


2,2  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

The  old  London  boot-maker  had  more  wisdom  than  most  of  the 
doctors  of  his  time. 

CHAPTER  III.    INFLUENCE  OF  SEA  AIR;  INLAND 
SEAS  AND  LAKES. 

SEA    VOYAGES 

The  value  of  sea  air  in  tuberculosis  has  been  discussed  pro  and 
con  for  ages  and,  like  the  tide,  there  is  an  ebb  and  flow  of  sentiment 
regarding  its  value  in  the  treatment  of  tuberculosis.  Undoubtedly 
there  is,  at  present,  a  stronger  belief  in  the  efficacy  of  sea  air  in 
the  various  forms  of  tuberculosis  than  at  any  previous  time.  This  is 
especially  true  as  regards  tuberculosis  of  the  bones,  the  tuberculosis 
of  children  and  in  the  important  class  of  cases  termed  fibroid  phthisis. 

Aretaeus,  about  250  B.  C,  recommended  sea  voyages  for  the  cure 
of  consumption,  and  300  years  later  Celsus  advocated  voyages  from 
Italy  to  Egypt,  if  the  patient  were  strong  enough.  Celsus  was  a 
layman  whose  learning  was  truly  encyclopedic,  but  only  his  medical 
writings  have  survived.  When  the  Roman  sufferer  from  tubercu- 
losis was  not  able  to  make  the  sea  voyage  to  Egypt  be  was  sometimes 
advised  to  pass  a  large  portion  of  his  time  sailing  on  the  Tiber.1 

At  Kreuznach,  Ems,  and  other  continental  resorts,  salt  inhalations 
are  given  to  patients  with  scrofulous  and  chronic  bronchial  affec- 
tions. Instead  of  trusting  to  sea  breezes  the  patients  are  taken  to 
halls  where  saline  particles  are  present  in  a  higher  precentage  than 
they  can  ever  be  at  the  sea  side.  They  inhale  the  salt-laden  air  and 
make  use  of  pulverization  apparatus.  Hours  are  spent  in  the  open 
air  near  the  "  evaporating  fences  "  so  as  to  inhale  salt  air  at  interior 
stations.  At  Ems  this  treatment  is  carried  out  in  pneumatic  cham- 
bers capable  of  holding  ten  people  in  compressed  atmosphere  for 
about  1%  hours. 

Sea  air  is  of  acknowledged  purity  as  to  micro-organisms,  dust  and 
adventitious  gases.  As  previously  remarked,  there  is  at  sea  a  maxi- 
mum of  ozone  and  a  minimum  of  all  foreign  deleterious  substances. 
(See  page  9.)  Without  considering,  as  yet,  the  amount  of  watery 
vapor  in  the  air  of  the  ocean  and  other  features  of  ocean  air  such  as 
its  movement  and  temperature,  we  recognize  some  physical  contents 
such  as  a  minute  quantity  of  sodium  chloride,  iodine  and  bromine 
as  characteristic  of  sea  air  when  contrasted  with  air  from  any  other 


1 "  Opus  est,  si  vires  patiuntur,  longa  navigatione,  coeli  mutatione,  sic 
ut  densius  quam  id  est,  ex  quo  discedit  aeger,  petatur ;  ideoque  aptissime 
Alexandriam  ex  Italia  itur."    Celsus,  De  Med.  lib.  in,  Cap.  22. 


SMITHSONIAN     MISXF  LLANE0U8    COLLECTIONS 


VOL.    63,    NO.    I,    FL. 


STORM   AT  BLACKPOOL,   ENGLAND.     SHOWING  HOW  SALINE   PARTICLES   ENTER  THE  ATMOSPHERE 
Photographs  by  Courtesy  of  Dr.   Leonard   Malloy 


NO.    I  AIR    AND    TUBERCULOSIS HINSDALE  33 

locality.  The  wind  carries  aloft  fine  particles  derived  from  the  crests 
of  the  waves  and  this  saline  matter  from  sea  water  and  foam  is 
constantly  present  near  the  surface  and  is  carried  for  miles  inland.1 
It  is  well  known  that  plants  near  the  seashore  have  a  perceptible 
coating-  of  saline  matter  which  modifies  their  growth. 

As  far  as  the  present  subject  is  concerned  we  have  to  deal  with 
the  influence  on  the  tuberculous  processes  exerted  by  a  marine  cli- 
mate. This  can  be  obtained  by  undertaking  sea  voyages  or  by  a 
residence  on  islands,  or  on  the  seaboard. 

Ocean  voyages  were  formerly  strongly  advocated  as  a  means  of 
cure  in  tuberculosis  and  were  given  an  extended  trial  especially  by 
English  physicians.  The  constant  commercial  intercourse  between 
England  and  her  possessions  all  over  the  world  made  the  practice 
easy  and  the  results  have  been  carefully  weighed.  Before  the  days 
of  steam  the  typical  ocean  voyage  from  London  to  China  or  India 
involved  vastly  different  conditions,  as  to  time,  route  and  accommo- 
dations. Some  features  will  always  be  the  same.  Seasickness,  the 
confined  air  of  cabins,  storm  and  wet  will  remain  to  harrass  and  ter- 
rify the  traveler.  But  the  clipper  ships  of  the  past  are  now,  for 
the  most  part,  doing  duty  as  coal  barges  and  the  steam  "  tramp  " 
and  ocean  liner  carry  the  cargoes  of  the  world. 

After  ruling  out  the  tramps,  cattle  ships,  and  the  coasting  schoon- 
ers, we  have  left  a  few  sailing  vessels  still  engaged  in  the  East 
India  trade  and  the  fast  liners.  Modern  systems  of  ventilation  and 
cold  storage  have  corrected  some  of  the  great  disadvantages  of  the 
past  and  the  presence  of  competent  surgeons  on  board  all  the  larger 
passenger  steamers  make  the  trip  comparatively  safe  for  a  tubercu- 
lous patient  if  the  necessity  arises  for  him  to  make  the  voyage.  But 
as  a  strictly  therapeutic  measure  such  trips  are  not  to  be  recom- 
mended and  in  this  we  are  supported  by  nearly  all  good  authorities.2 


1  Two  illustrations  from  a  storm  at  Blackpool,  England,  are  supplied  by 
the   courtesy  of   Dr.   Leonard   Molloy. 

2  Huggard,  A.,  Handbook  of  Climatic  Treatment,  London,  1906,  says  :  "  Sea 
voyages  were  formerly  in  great  repute  for  persons  with  phthisis ;  but  it  is 
now  recognized  that,  except  in  certain  well-defined  instances  they  generally 
do  harm.  Only  slight  or  mild  cases  without  fever  and  without  active  symp- 
toms, are  likely  to  benefit.  The  patients  most  suitable  for  a  sea  voyage  are 
those  in  whom  the  disease  has  become  partly  or  entirely  arrested."  Dr. 
Burney  yet  doubts  whether  phthisis  at  any  stage  is  benefited  by  ocean  travel. 
Prof.  Charteris,  of  Glasgow,  approves  of  a  sea  voyage  in  the  early  stage  of 
phthisis  in  a  young  person,  but  after  that  stage  all  experience  testifies  that 
degeneration  proceeds  more  rapidly  on  sea  than  on  shore  and  the  patient, 
if  he  reaches  land,  only  does  this  to  find  a  grave  far  away  from  the  surround- 
ings of   friends  and  home. 


34  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

Dr.  W.  E.  Fisher,  for  many  years  surgeon  to  the  Pacific  Mail 
Steamship  Co.,  while  observing  that  patients  affected  with  chronic 
diseases,  such  as  phthisis,  dyspepsia,  etc.,  are  not  so  liable  to  seasick- 
ness as  others,  states  that  a  large  percentage  of  tuberculous  patients 
stand  the  sea  voyage  badly.  Dr.  Fisher's  experience  relates  to  the 
trip  from  New  York  to  San  Francisco  by  way  of  Panama.  During 
the  first  part  of  the  voyage  until  the  Bahama  Islands  are  reached, 
the  invalid  experiences  bracing  weather.  From  that  point  to  the 
Isthmus  and  thence  up  the  coast  during  the  long  voyage  of  three 
weeks  or  more,  a  distance  of  nearly  three  thousand  miles,  the  tem- 
perature averages  900  in  the  shade  and  on  many  days  rises  as  high 
as  950  or  960  F.  This  occurs  during  the  winter  months  and  is 
the  direct  cause  of' deaths  on  the  voyage  or  shortly  after  arrival  on 
the  California  coast. 

Dr.  R.  W.  Felkin,  of  Edinburgh,  says:1  "  Fifteen  years  ago  I  used 
to  advocate  sea  voyages  in  my  lectures  on  Climatology  in  Edin- 
burgh, with  great  confidence ;  now  I  am  more  cautious.  I  do  not 
send  phthisical  patients  to  sea  as  I  once  did.  The  risk  of  spreading 
infection  is,  to  my  thinking,  too  serious  to  be  incurred.  I  well 
remember  once  sending  two  sisters  to  Australia ;  the  elder  suffered 
from  phthisis ;  the  younger  was  healthy.  The  elder  certainly  did 
gain  some  temporary  benefit,  but  the  younger  sister  and  also  a  cabin 
companion  became  infected,  and  all  three  girls  were  in  their  graves 
within  a  year  of  their  return  to  this  country.  I  am  sure  that  occupy- 
ing a  joint  cabin  as  they  did  caused  the  mischief." 

Dr.  F.  Parkes  Weber,  of  London,  takes  a  more  hopeful  view.2  He 
says  that  sea  voyages  are  often  useful  in  the  milder  and  quiescent 
forms  of  pulmonary  tuberculosis,  provided  the  patient's  general  con- 
dition be  such  as  otherwise  to  fit  him  for  life  on  shipboard.  "  Long 
voyages  are  to  be  preferred  to  all  other  methods  of  treatment  in  the 
case  of  male  patients  who  have  a  taste  for  the  sea,  who  are  strong 
physically,  or  who  possessed  an  originally  strong  constitution  and 
were  infected  by  '  chance '  or  when  weakened  by  overwork,  worry, 
improper  hygienic  conditions,  or  acute  diseases." 

In  pulmonary  tuberculosis  complicated  by  syphilis,  or  syphilitic 
phthisis,  as  it  was  formerly  designated,  a  marine  climate  seems  to 
be  particularly  suitable.3 


1  Journal   of   Balneology   and    Climatology,  January,    1906. 

2  F.   Parkes  Weber :     System   of    Physiologic   Therapeutics,  Vol.  3,   p.  87, 
Philadelphia,    1901. 

3  See  Roland  G.  Curtin,  Trans.  Amer.   Climatological  Ass.,  Vol.  4,  p.   31. 


NO.    I  AIR    AXD   TUBERCULOSIS — HINSDALE  35 

The  vicissitudes  of  sea-travel,  the  narrow  cabins  and  the  difficulty 
of  obtaining  a  suitable  diet,  even  such  common  requisites  as  milk  and 
eggs,  should  be  enough  to  condemn  this  plan.  Tuberculosis  patients 
ought  not  to  travel  more  than  is  absolutely  necessary.  Imagine  the 
bacteriological  condition  of  a  consumptive's  stateroom,  for  instance, 
at  the  end  of  a  month's  voyage !  What  sea-captain  or  steward  would 
ever  put  such  a  cabin  into  a  sanitary  condition  for  the  next  pas- 
senger? 

The  author  has  some  experience  of  life  at  sea  under  both  sail  and 
steam,  although  he  has  never  taken  very  prolonged  voyages.  Taking 
into  account  the  character  of  the  food  supply  and  the  necessity  of  at 
least  sleeping  in  small  cabins  and  probably  spending  days  in  them, 
with  uncertain  medical  attention;  and,  besides  this,  the  dangers  of 
various  kinds  that  pertain  to  seaports,  the  author  feels  bound  to  con- 
demn sea  voyages  for  the  tuberculous  in  any  stage. 
" Non  mutant  morbiim  qui  transeunt  mare." 
MARINE  CLIMATE  OF  ISLANDS 

It  is  far  better  for  the  tuberculous  patient  to  remain  on  terra  firma 
than  to  traverse  the  sea.  Whatever  is  of  value  in  the  sea  air  can  be 
obtained  in  islands  such  as  Ireland,  the  Isle  of  Man,  the  Isle  of 
Wight,  Nantucket,  the  Isles  of  Shoals,  Newfoundland,  Long  Island, 
the  Bahamas,  the  Canaries,  the  Philippines,  Samoa,  and  many  other 
islands. 

Just  as  in  the  case  of  sea  voyages,  there  are  concomitant  influ- 
ences, many  of  which  are  notoriously  unfavorable,  that  in  themselves 
over-balance  any  possible  advantage  from  sea  air.  Take,  for  in- 
stance, the  problem  as.it  presents  itself  in  Ireland  or  the  Isle  of  Man. 

Among  the  various  countries  of  the  world  Ireland  stood  fourth 
in  the  order  of  mortality  from  tuberculosis,  being  exceeded  by  Hun- 
gary, Austria,  and  Servia.  During  the  last  thirty-five  years  the 
mortality  in  Great  Britain  has  been  reduced  one-half  among  females 
and  one-third  among  males  but,  until  1907,  there  had  been  no  such 
fall  in  Ireland. 

Sir  John  Byers,  of  Belfast,  in  his  address1  entitled  "  Why  is 
Tuberculosis  so  Common  in  Ireland?"  characterized  its  prevalence 
in  that  country  as  "  appalling."  Among  the  nine  causes  which  are 
assigned  for  this  condition  of  affairs  attention  is  first  directed  to 
the  damp  climate.    An  investigation  of  places  with  rather  worse  con- 


1  The  Lancet,  January  25,  1908.    See  also  Alfred  E.  Boyd,  M.  B. :   Tubercu- 
losis and  Pauperism  in  Ireland,  British  Journ.  Tuberculosis,  July,  1908,  p.  159. 


36  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

ditions  of  climate  led  Sir  John  to  say  on  this  point:  "I  cannot, 
therefore,  admit  that  there  is  much  in  the  dampness  of  the  atmos- 
phere as  a  cause  of  tuberculosis  in  Ireland."  Sir  William  Osier 
takes  precisely  the  same  ground  and  pointed  out  at  the  opening  of 
the  Tuberculosis  Exhibit  in  Dublin,  that  Cornwall,  with  a  much 
damper  atmosphere  than  that  of  Ireland,  was  so  free  from  the 
disease  that  consumptives  were  sent  there.  In  Cardiff,  Wales,  with 
a  damp  climate  and  with  the  ground  water  in  many  places  near  the 
surface  in  the  gravel  and  with  the  lower  part  of  the  town  on  a  stiff 
marine  clay,  very  retentive  of  moisture,  the  tuberculosis  death  rate 
for  1906  was  only  1.20  per  1,000.  On  the  other  hand  in  Belfast, 
with  a  smaller  rainfall  (34.57  inches  as  against  42.43  inches)  the 
mortality  was  more  than  twice  as  much,  or  2.77  per  1,000.  The 
figures  for  1906  were : 

Death  rate 
from 
Rainfall  tuberculosis 

inches  per  iooo 

Manchester,  notoriously  damp,  foggy  and  smoky 1.82 

Liverpool 1.82 

London 1.42 

Cardiff,  Wales  42.81  1.20 

Bolton,    England 42.43  1.11 

Belfast,  Ireland 34.57  2.77 

Cork '.  .  4.53 

Dublin,  Ireland   27.73  2-91 

North  Dublin,  Ireland 4.70 

After  taking  up  in  turn  dampness  of  soil,  emigration  as  a  cause 
for  tuberculosis,  the  asserted  susceptibility  of  the  Irish  to  tuberculo- 
sis, poverty  and  social  position,  food  and  drink  and  industries,  and 
after  weighing  them  carefully  they  were  all  discarded  as  insufficient 
causes  of  this  mortality.  The  prime  cause  was  declared  to  be  ivant 
of  Sanitary  Reform  and  the  prevalent  domestic  or  home  treatment 
of  the  advanced  cases  of  pulmonary  tuberculosis. 

Since  1907  an  encouraging  decline  in  the  mortality  from  tuber- 
culosis has  been  noted.  Whereas  the  rate  for  both  sexes  throughout 
Ireland  was  273.6  per  100,000  in  1907  it  had  dropped  by  gradual 
stages  to  215.2  in  1912.  Sir  William  Thompson,  the  General  Register 
for  Ireland,  justly  attributes  this  well  marked  decrease  during  the 
past  six  years  to  the  exertion  of  Her  Excellency,  the  Countess  of 
Aberdeen.1 


1  Trans.  National  Association  for  the  Prevention  of  Consumption  and 
Other  Forms  of  Tuberculosis,  5th  Annual  Conference,  London,  August  4 
and  S,  1913.    See  also  Sir  John  Moore,  Interstate  Medical  Journ.,  April,  1914. 


NO.    I  AIR    AND   TUBERCULOSIS — HINSDALE  37 

Sir  William  shows  that  this  decrease  indicates  17,000  fewer  people 
suffering  from  tuberculosis  in  Ireland  in  1912  than  there  were  in 
1907.  This  corresponds  to  a  decrease  of  nearly  one-fifth  of  the 
total  number  of  cases  of  tuberculosis.  He  seems  hopeful  that  within 
the  next  few  years  the  death-rate  from  tuberculosis  in  Ireland  will 
not  be  above  the  average  in  other  countries. 

Undoubtedly  hygienic  and  philanthropic  measures  are  entitled  to 
the  credit  for  this  marked  improvement  and  it  gives  us  pleasure  to 
note  in  this  connection  the  remarkable  work  of  Her  Excellency,  the 
Countess  of  Aberdeen.  This  noble  woman  founded  in  1907  the 
Women's  National  Health  Association  of  Ireland  and  a  vigorous 
campaign  was  started  which  soon  roused  the  whole  country  to  a 
sense  of  responsibility  in  matters  of  public  health  and,  in  particular, 
to  measures  necessary  for  the  prevention  and  cure  of  tuberculosis. 
The  influence  of  this  organization  rapidly  spread  and  within  eight- 
een months  no  less  than  seventy  branches  had  been  opened  through- 
out Ireland,  for  the  most  part  opened  in  person  by  their  excellencies, 
the  Lord  Lieutenant  and  Countess  of  Aberdeen,  and  now  it  has  150 
branches  and  18,000  members. 

While  undertaking  the  reduction  of  infant  mortality,  the  improve- 
ment in  the  milk  supply  and  better  school  hygiene,  the  association 
made  a  systematic  attack  on  the  prevalence  of  tuberculosis.  This 
included  home  treatment  and  its  strong  ally,  the  tuberculosis  dis- 
pensary, on  a  plan  similar  to  that  originated  by  Sir  Robert  Philip,  of 
Edinburgh  ;  it  included  sanatorium  treatment ;  and  it  provided  special 
treatment  for  advanced  cases  of  tuberculosis.  In  this  phase  of  the 
work  the  association  had  the  benefit  of  £145,623.  through  the  pro- 
visions of  the  National  Insurance  Act.  Charitable  Americans  also 
contributed  handsomely  toward  the  erection  of  sanatoria  now  com- 
prising one  thousand  beds,  the  maintenance  of  dispensaries  and  of 
depots  for  the  supply  of  pasteurized  milk.1 

It  is  interesting  to  note  that  the  Association  also  lent  its  support 
to  the  formation  of  an  "  Irish  Goat  Society,"  believing  that  the  best 
way  to  meet  the  scarcity  of  milk  experienced  in  many  parts  of  Ire- 
land is  to  encourage  the  keeping  of  a  good  breed  of  milking  goats. 
Then,  too,  through  the  administration  of  the  Laborer's  Acts  nearly 
fifty  thousand  cottages  with  garden  plots  ranging  up  to  one  acre 
have  been  built  for  rural  laborers  by  rural  sanitary  authorities  at  an 
outlay  of  over  £8,000,000. 

We  have  cited  this  remarkable  campaign  of  the  anti-tuberculosis 


1  The  late  Mr.  R.  J.  Collier  and  Mr.  Nathan  Straus. 


38  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

movement  in  Ireland  to  show  how  close  are  its  relation  to  the  broader 
field  of  general  hygiene  and  sanitation  and  to  show  that  such  work 
pays ;  and  furthermore  what  great  service  one  person  of  noble  birth, 
by  her  foresight,  solicitous  care  and  untiring  devotion,  can  initiate 
and  carry  out.  As  Prof.  Thompson  says :  There  is  no  doubt  that 
it  will  rank  as  one  of  the  greatest  philanthropic  efforts  of  our  time. 
Take  the  Isle  of  Man.  This  island  in  the  Irish  Sea  has  a  popula- 
tion of  over  ten  thousand  and  for  six  hundred  years  has  been  singu- 
larly free  from  the  admixture  of  English,  Irish,  or  Scotch  blood. 
The  island  has  a  more  equable  climate  than  any  other  part  of  the 
British  Isles.  The  mean  annual  temperature  is  49  °  F.  There  is  com- 
parative absence  of  frost,  fog,  or  snow.  But  careful  records  since 
1880  show  that  the  Manx  tuberculosis  death  rate  is  about  double 
that  on  the  mainland.1 

1880-82  1883-189- 

Isle  of  Man 31-63  25.70  per  10,000 

1887  1893 

England  and  Wales i5-o8  13.07  per  10,000 


14.28  12.17  per  10,000 

1889  1895 

14.35  I243  per  10,000 

1890  1896 

15.06  H-39  per  10,000 

The  Bahamas  and  Bermuda  in  the  Atlantic  Ocean  have  a  sub- 
tropical marine  climate  that  experience  shows  to  be  far  too  relaxing 
and  enervating  for  tuberculous  patients. 

The  Philippines  and  all  other  tropical  islands  are  likewise  entirely 
unsuited  for  tuberculous  patients  for  the  same  reasons.2  Newfound- 
land, with  a  harsh,  damp,  colder  air,  is  equally  bad. 

Dr.  Newsholme,  of  Brighton,  President  of  the  Epidemiological 
Section  of  the  Royal  Society  of  Medicine,  in  an  elaborate  inquiry 
into  the  principal  causes  of  the  reduction  of  the  death  rate  from 
phthisis  in  different  countries,  came  to  the  conclusion  that  the  one 


1  Charles  A.  Davies,  M.  D. :  Tuberculosis  in  the  Isle  of  Man  (Tuberculosis, 
London,   Oct.,    1900). 

2  According  to  Dr.  Issac  W.  Brewer,  U.  S.  A.,  "  Notes  on  the  Vital  Sta- 
tistics of  the  Philippine  Census  of  1903,"  American  Medicine,  Oct.,  1906,  the 
death  rate  from  tuberculosis  is  one-third  that  in  the  United  States. 


NO.    I  AIR    AND    TUBERCULOSIS HINSDALE  39 

common  factor  present  in  all  cases  where  a  fall  was  noted  was  the 
segregation  of  the  patients  in  hospitals  or  sanatoria.  In  each  country 
where  the  institutional  has  replaced  the  domestic  relief  of  destitu- 
tion there  has  been  a  reduction  of  the  death  rate  from  phthisis  which 
is  roughly  proportional  to  the  change. 

As  to  the  cause,  then,  of  the  spread  of  tuberculosis,  we  shall  find 
that  it  probably  always  lies  in  ignorance,  indifference  and  other  moral 
or  sociologic  causes,  and,  in  many  of  the  cases  cited,  not  to  climatic 
or  atmospheric  conditions. 

Our  opinion  of  sea  air  is  fortunately  not  confined  to  that  of  the 
high  seas  or  even  that  of  islands.  The  sea  air  sweeps  the  mainland 
and,  as  we  know,  modifies  the  climate  of  all  adjacent  portions  of  the 
Continent.  The  great  source  of  atmospheric  moisture  is  found  ulti- 
mately in  the  oceans.  The  invisible  watery  vapor  and  the  visible 
clouds  are  carried  inland  and  deposit  their  water  over  the  Continent. 
The  monsoons  which  are  most  highly  developed  in  India  and  other 
parts  of  Asia,  prevail  also  in  Texas  and  on  the  Pacific  coast  of  the 
United  States.  These  seasonal  winds  are  of  great  importance  from 
a  climatic  standpoint  and  hence  should  be  taken  into  account  in  ref- 
erence to  the  climatic  treatment  of  tuberculosis.1  During  the  sum- 
mer and  autumn  in  India  these  seasonal  winds  sweep  inland  from  the 
sea  and  deluge  the  country  with  rain.  This  amounts,  in  the  Khasi 
Hills,  200  miles  north  of  the  Bay  of  Bengal,  to  between  500  and  600 
inches  a  year  and  reaches  its  maximum  at  points  about  1,400  meters, 
4,600  feet,  above  sea  level. 

Fortunately  in  the  United  States  these  seasonal  winds,  while  pres- 
ent, are  not  so  dominant  as  climatic  factors.  We  are  more  concerned 
in  the  present  study  with  the  diurnal  winds  of  the  seashore.  The  sea 
breeze  which  tempers  the  heat  of  our  coasts  is  a  distinctly  beneficial 
feature  of  the  shore  and  not  only  tends  to  moderate  the  heat  of 
the  summer  day,  but  sweeps  inland  for  fifty  or  a  hundred  miles  the 
pure  ocean  air  and  provides  all  the  desirable  features  of  a  marine 
climate. 

ARCTIC    CLIMATE 

Passing  still  farther  north  we  have  the  Arctic  climate.  It  is 
marine  or  insular  and  cold.  Arctic  voyages  have  been  proposed  for 
the  treatment  of  tuberculosis  and,  as  adjuncts  to  the  voyage,  a  sum- 
mer sojourn  in  the  northern  fjords  of  Greenland.     A  trip  of  this 


1  See  William  Gordon :  The  Influence  of  Strong,  Rainbearing  Winds  on 
the  Prevalence  of  Phthisis,  H.  K.  Lewis,  London,  1910,  Observations  in 
Devonshire. 


40  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

kind  has  been  seriously  planned  by  Dr.  Frederick  Sohon,  of  Wash- 
ington, D.  C,  but  has  never  yet  been  carried  out.1 

It  is  a  significant  fact  that  Arctic  explorers  from  Dr.  Elisha  Kent 
Kane  down,  including  General  A.  W.  Greely,  Admiral  Peary,  Mr.  W. 
S.  Champ,  Mr.  Herbert  L.  Bridgman,  the  late  Dr.  Nicholas  Senn,  and 
others  comment  on  the  healthfulness  of  the  Polar  climate.  Dr. 
Sohon  made  two  voyages  with  Commander  Peary,  in  1896  and  in 
1902,  and  states  his  opinion  that  in  summer  the  Arctic  regions  are  en- 
tirely suitable  for,  and  beneficial  to,  the  tuberculous,  and  that  the  un- 
equaled  natural  advantages  for  a  cure  can  be  practically  utilized.  Few 
understand  the  fascination  which  the  Polar  regions  undoubtedly 
exert  on  all  who  enter  that  charmed  circle.  The  expressions  used  by 
Arctic  explorers  seem  so  extravagant  to  the  average  mind.  The 
late  Professor  Senn  says :  "  Nature  there  lends  such  efforts  toward 
prophylaxis,  as  to  leave  no  need  for  therapeutics."  '' 

The  air  of  the  Arctic  regions  is  free  from  dust  and  germs.  It  is 
not,  in  itself,  responsible  for  any  disease  which  may  be  carried 
into  Arctic  settlements  by  ships'  crews,  or  by  means  of  the  migration 
of  .animals  or  birds.  Colds  and  catarrhal  conditions  are  conspicu- 
ously absent.  There  is  no  pneumonia.  The  only  "  Arctic  Fever  " 
is  that  which  explorers  are  almost  sure  to  contract  on  their  first 
visit  and  which  has  an  annual  periodicity.  It  is  not  a  self-limited 
disease,  as  Admiral  Peary  can  testify  after  nearly  fourteen  con- 
secutive summers  in  the  Polar  regions. 

Another  feature  of  the  atmosphere  in  the  Arctic  is  absolute 
clearness  and  abundance  of  sunshine.  Dr.  Sohon,  in  1902,  exposed 
dishes  of  agar  and  introduced  into  culture  tubes  pebbles,  bits  of 
vegetation  and  water  from  the  ground  and  from  pools  at  Comman- 
der Peary's  winter  quarters.  Of  six  dishes  exposed  for  from  one- 
half  to  two  hours,  two  were  sterile  and  four  gathered  only  a  com- 
mon white  mould  (P.  glaucum).  Only  the  hay  bacillus  was  obtained 
from  the  pebbles.  Water  yielded  the  hay  bacillus,  B.  liqaefaciens, 
B.  Huorescens  and  an  unclassified  non-pathogenic  saprophytic  rod  or- 
ganism. 


^Frederick  Sohon,  M.  D. :  Personal  Observations  on  the  Advantages  of  Cer- 
tain Arctic  Localities  in  the  Treatment  of  Tuberculosis  (American  Medicine, 
April  23,  1904). 

Idem.  The  Therapeutic  Merits  of  the  Arctic  Climate  Meteorological  Data 
of  a  Summer  Cruise  (Journal  American  Medical  Association,  February  3, 
1906). 

2 Nicholas  Senn:  Medical  Affairs  in  the  Heart  of  the  Arctics  (Journal 
American   Medical   Association,    1905,   Vol.   45,   pp.    1564,    1647). 


NO.    I  AIR    AND   TUBERCULOSIS — HINSDALE  4 1 

The  atmosphere  has  a  bracing  quality  and  is  always  credited  with 
developing  a  prodigious  appetite.  It  is  pointed  out  that  a  taste  is 
developed  for  the  kind  of  food  the  tuberculous  patient  needs,  viz., 
fatty  food  and  meat.  The  craving  for  this  kind  of  food  is  usually 
accompanied  by  a  corresponding  adaptability  to  digest  it  and,  in 
healthy  subjects,  flesh  is  always  gained.  Dr.  Sohon  says  that  in 
both  of  his  trips  to  Greenland  he  has  exceeded  his  usual  maximum 
weight,  gaining  the  first  time  thirty  pounds  in  two  months,  and  the 
second  time  nineteen  pounds  in  six  weeks.  In  the  latter  voyage 
even  the  crew  made  an  average  gain  of  ten  pounds  in  weight. 

A  large  share  of  the  beneficial  influence  of  any  atmospheric 
change  is  that  which  conduces  to  a  good  appetite  and  digestion. 
In  this  respect  the  summer  Arctic  voyage  may  fairly  claim  pre- 
eminence. With  qualities  such  as  these  it  is  natural  that,  for  a  por- 
tion of  the  year  at  least,  the  merits  of  the  Arctic  climate  in  the  treat- 
ment of  tuberculosis  should  at  least  be  considered. 

An  atmospheric  feature  is  its  great  penetrability  for  light  and 
especially  for  the  actinic  and  ultra-violet  rays.  Tanning  of  the  skin 
always  occurs  and  sunburn  is  not  uncommon.  During  summer 
the  sun  never  sets  and,  though  not  very  high  in  the  heavens,  its 
generous  rays  must  exert  a  very  beneficial  influence  on  any  morbid 
process,  especially  of  a  tubercular  type.  Arctic  plants  develop  rap- 
idly from  seed  to  flower  and  seed  again  in  surprising  manner  and 
the  wild  animals  seem  to  be  the  largest  and  most  vigorous  of  their 
kind. 

In  judging  of  the  weather  to  be  encountered  in  the  Arctic  regions, 
we  are  too  much  inclined  to  recall  the  harrowing  accounts  of  the 
ill-fated  expeditions  of  the  past;  but  in  the  Northern  fjords  of 
Greenland,  some  miles  from  the  coast,  or  in  the  protected  inland 
bays,  the  atmospheric  conditions  of  summer  are  quite  agreeable 
and  are  especially  suitable  for  the  open  air  treatment. 

The  fluctuations  of  temperature  are  very  moderate.  The  average 
minimum  temperature  between  July  28  and  September  6,  between 
690  and  780  north  latitude  on  these  Greenland  Fjords,  was  about 
38  F. ;  the  average  maximum  was  49  °  to  500.  Temperatures  as 
high  as  560  were  recorded  at  North  Star  Bay  and  about  520  at  Etah. 

The  humidity  averaged  low.  The  records  were  made  at  8  a.  m. 
and  8  p.  m.,  and,  owing  to  the  constant  daylight,  are  much  more 
representative  estimates  of  relative  humidity  than  in  the  case  of 
records  of  relative  humidity  at  those  same  hours  in  temperate  lati- 
tudes. 


42  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

Maximum  Minimum  Average 

Humidity  Humidity 

8  a.  ro.        8  p.  m.       8  a.  m.       8  p.  m.  8  a.  m.  8  p.  m. 

New  York    100  95  62  50  81.3  74.1 

Denver  90  90  41  13  66.1  37.1 

North  Star  Bay   72  71  56  39  63.1  54. 

Etah,  Greenland 81  70  40  35  57.6  52.4 

The  relative  humidity  was  much  lower  while  at  anchor  in  the 
harbors  of  Northern  Greenland  than  while  en  route  through  the 
Strait  of  Belle  Isle  and  off  Labrador  and  in  Davis  Strait  and  Smith's 
Sound. 

We  have  given  some  attention  to  this  subject  on  account  of  the 
very  enthusiastic  claims  made  on  behalf  of  the  atmosphere  of  the 
Arctic  regions  during  summer  treatment  of  tuberculosis.  Although 
the  plans  for  sending  a  ship  with  tuberculous  passengers  on  this 
voyage  failed  to  be  carried  out  owing  to  inability  to  get  the  neces- 
sary permission  from  the  Danish  Government  to  land  at  the  north- 
ern ports  of  Greenland,  it  is  possible  that  at  some  future  time  the 
attempt  will  again  be  made. 

The  fact  that  Icelanders  and  Greenlanders  may  contract  tubercu- 
losis in  numbers  and  may  die  from  it  is  not  to  be  overlooked;  but 
the  filth  of  winter  quarters  in  the  far  North  and  the  foul  air  of 
these  huts  is  responsible  for  much  of  the  illness  of  the  native  inhabi- 
tants. The  Eskimo  survives  the  dangers  of  the  winter  because  he 
leads  a  totally  different  life  in  summer.  It  is  difficult  for  those  who 
have  never  been  to  the  Polar  regions  to  realize  what  a  change  is 
wrought  by  the  advent  of  constant  sunlight.  This  unique  feature 
of  the  summer  climate  contributes  to  health  and  energy.  The  at- 
mosphere, free  from,  all  germs  and  dust,  bracing  in  its  quality,  is 
a  strong  stimulant  to  bodily  functions  as  gain  in  weight  testifies. 

As  a  practical  measure  for  the  treatment  of  tuberculosis  Arctic 
voyages  have  not  yet  been  proved  to  be  beneficial,  although  there  is 
some  presumptive  evidence  in  their  favor  and,  in  view  of  the  abund- 
ance of  proof  that  the  disease  can  be  successfully  combated  at 
numberless  places  on  the  continent,  such  expeditions  will  scarcely 
meet  with  favor. 

FLOATING   SANATORIA 

In  1896,  Mr.  M.  O.  Motschoutkovsky  *  advocated  floating  sanatoria 
for  patients  with  incipient  tuberculosis.  These  specially  fitted  ves- 
sels were  to  be  shifted  from  port  to  port  according  to  the  season 
so  as  to  get  the  most  favorable  climatic  conditions. 


1  The  Lancet,   April  4,   1906,  p.  939. 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL. 


OPEN   AIR  CLASS  ON   FERRY  BOAT      SOUTHFIELD,"   EAST  RIVER,   NEW  YORK  CITY.     SLEEPING  HOUR 

Courtesy  of  Dr.  J.  W.   Brannan 


OPEN  AIR  SCHOOL  FOR  TUBERCULOUS  CHILDREN.     FERRY  BOAT      'SOUTHFI  ELD,"   BELLEVUE 
HOSPITAL.     SEE   PAGE   43 


NO.    I  AIR    AND   TUBERCULOSIS— HINSDALE  43 

The  vicissitudes  of  sea-travel,  the  narrow  cabins  and  the  difficulty 
of  obtaining  a  suitable  diet;  even  such  common  requisites  as  milk 
and  eggs,  ought  to  be  enough  to  condemn  this  plan.  Tuberculous 
patients  ought  not  to  travel  more  than  is  absolutely  necessary. 
Old  ferry  boats  have  been  recently  utilized  in  New  York  as  class- 
rooms for  tuberculous  scholars.  The  ferry  boat  "  Southfield  "  has 
been  equipped  for  this  work  through  the  Miss  Spence's  School 
Society  under  the  direction  and  courtesy  of  Bellevue  Hospital  in 
cooperation  with  Dr.  John  Winters  Brannan  and  Dr.  J.  Alexander 
Miller. 

There  are  three  classes  on  the  "  Southfield  " ;  two  for  pulmonary 
cases  of  about  thirty-six  children ;  these  classes  being  part  of  the 
regular  Bellevue  Clinic  work  and  entirely  supported  by  Bellevue. 

The  third  class  is  for  tuberculous  cripples  with  about  twenty 
children.  The  cost  of  nurses  and  special  equipment  for  this  class 
together  with  incidental  expenses  is  borne  by  the  Spence  School 
Society. 

The  teachers  for  all  three  classes  are  supplied  by  the  New  York 
Board  of  Education  so  that  they  are  a  part  of  the  regular  school 
system.1 

Owing  to  the  fact  that  these  old  ferry  boats  seem  to  answer  a 
useful  purpose  and  in  view  of  the  reported  use  by  the  Italian  Gov- 
ernment of  three  discarded  men-of-war  as  floating  sanatoria  in  the 
treatment  of  tuberculous  patients,  a  request  was  made  to  the  Navy 
Department  of  the  United  States  for  similar  ships  by  the  Fourth 
International  Congress  on  School  Hygiene  at  Buffalo,  N.  Y.,  August 
29,  1913,  in  a  resolution,  a  portion  of  which  is  as  follows: 

Whereas,  It  has  been  demonstrated  in  New  York  and  other  cities  that 
discarded  vessels  lend  themselves  admirably  to  transformation  into  all-year- 
round  hospitals  and  sanatoria  for  consumptive  adults,  sanatoria  for  children 
afflicted  with  joint  and  other  types  of  tuberculosis,  and  into  open  air  schools 
for  tuberculous,  anemic,  and  nervous  children ; 

Resolved,  That  the  fourth  International  Congress  on  School  Hygiene  peti- 
tions the  United  States  Government  to  place  at  the  disposal  of  the  various 
States  of  the  Union  as  many  of  the  discarded  battleships  and  cruisers  as  possi- 
ble to  be  anchored  according  to  their  size  in  the  rivers  or  at  the  seashore  and 
to  be  utilized  by  the  respective  communities  for  open  air  schools,  preven- 
toria,  sanatorium  schools  for  children,  or  hospital  sanatoria  for  adults. 

The  Secretary  of  the  Navy,  however,  for  the  following  very  good 
reasons,  declined. 


See  Buffalo  Medical  Journal,  1907-8,  Vol.  63,  41. 


44  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

I  am  of  the  opinion  that  battleships  are  not  suitable  for  floating  sanatoria. 
This  opinion  is  based  on  the  following  reasons. 

The  cost  of  maintaining  a  battleship  in  proper  sanitary  and  structural 
condition   is   very  high. 

Battleships,  particularly  the  older  types,  have  very  limited  deck  space,  and 
this  is  so  cut  up  by  hatches,  turrets,  davits,  cranes  and  winches  that  there 
are  few  spaces  large  enough  for  a  cot.  The  cost  of  removing  these  obstruc- 
tions would  be  equivalent  to  that  of  building  more  suitable  floating  hospitals. 

The  ventilation  in  the  enclosed  spaces  of  these  vessels  is  so  poor  that  it 
often  has,  an  unfavorable  effect  on  those  chosen  especially  for  their  health 
and  vigor.  Its  effect  on  those  already  diseased  could  not  be  favorable. 
The  openings  are  very  small  and  admit  but  little  sunlight;  it  is  necessary 
to  use  artificial  light  for  a  large  part  of  the  day.  To  correct  these  conditions 
would  involve  great  expense,  even  if  it  were  possible  of  accomplishment. 

The  passages  are  narrow,  the  ladders  steep  and  the  hatches  small,  making 
transportation  of  the  sick  very  difficult. 

Very  respectfully, 

Josephus  Daniels, 

Secretary  of  the  Navy. 

Under  the  title  "  Una  nave-scula-sanatorio  per  fanciulli  predis- 
posti "  Federico  di  Donato  has  urged  this  plan  in  Italy  but  up  to  the 
present  the  Italian  Government  has  not  assented. 

The  remark  has  been  made  that :  "  If  the  right  sort  of  ship  could 
be  sent  to  the  right  place  in  the  right  kind  of  weather  with  the 
right  sort  of  patients,  a  great  deal  of  good  might  result." 

SEASIDE    SANATORIA    FOR    CHILDREN 

In  the  United  States  notable  attempts  have  been  made  to  utilize 
sea  air  in  treating  tubercular  disease  in  children.  Individual  cases 
have  been  treated  by  sea  air,  but  on  a  larger  scale  we  should  mention 
the  experience  of  two  institutions. 

In  1872,  Dr.  William  H.  Bennett,  of  Philadelphia,  established  the 
Children's  Seashore  House  at  Atlantic  City,  New  Jersey.  This  in- 
stitution is  open  during  the  entire  year,  and  in  1912  more  than  3,500 
mothers  and  children  were  cared  for.  Among  the  first  patients  ad- 
mitted to  the  Institution  at  its  inception  were  the  hospital  children 
suffering  from  tubercular  diseases  of  the  bones,  glands,  and  joints. 
The  wonderful  improvement  wrought  in  such  cases  by  the  sea  air 
led  to  a  steadily  increasing  demand  for  their  admission,  and  now 
throughout  the  year  seventy  beds  are  set  apart  for  their  care  and 
treatment. 

The  most  notable  and  most  recent  attempt  in  the  United  States 
to  treat  cases  of  tuberculosis  of  the  bones,  joints  and  lymph  nodes 
is   at  the   Sea   Breeze   Hospital   at   Coney   Island   on   the   Atlantic 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1.    PL,    t1 


TREATMENT    OF    POTT'S    DISEASE    OF   THE   SPINE   ON   A  BRADFORD  FRAME.     SEA  BREEZE 
HOSPITAL,    SEA    GATE,   NEW    YORK.      PATIENTS    REMAIN    FOR    MONTHS,   NIGHT  AND    DAY,  ON 
THESE  FRAMES,   BUT  ARE  REMOVED  TWICE  DAILY  FOR  BATHING  AND  POWDERING 
Courtesy  of  Dr.  J     W.    Brannan 


SEA  BREEZE  HOSPITAL,  SEA  GATE,  CONEY  ISLAND,  NEW  YORK.  MORE  CITY  CHILDREN  ARE 
STARVED  FOR  SLEEP  THAN  FOR  FOOD.  VIEW  AT  6  A.  M.  IN  SPRING.  CHILDREN  SLEEPING  TEN 
HOURS  ON   PORCH  ALL  NIGHT.     CANVAS  OVERHEAD   ROLLED  BACK. 


NO.    I  AIR    AND    TUBERCULOSIS — HINSDALE  45 

Ocean,  ten  miles  from  New  York  City.  This  was  undertaken  by  the 
New  York  Association  for  Improving  the  Condition  of  the  Poor. 
Ten  tents  were  erected  on  the  beach  and  were  opened  to  children 
between  the  ages  of  two  and  fourteen  on  June  6,  1904.  These 
tents  had  a  capacity  of  fifty  patients.  In  the  autumn  permanent 
buildings  were  occupied  and  have  since  been  used.  While  the 
main  reliance  has  been  on  fresh  sea  air  and  good  food,  the  very  best 
surgical  aid  has  been  employed,  and  for  all  major  operations  the  chil- 
dren were  temporarily  removed  to  hospitals  in  New  York  City. 
This  co-operative  arrangement  is  a  great  advantage  to  the  seashore 
institution,  as  the  distance  is  not  great  and  avoids  the  necessity  of 
enlarging  the  surgical  staff  and  at  the  same  time  provides  the  highest 
surgical  skill.  To  avoid  mistakes  most  of  the  cases  admitted  are 
seen  by  at  least  one  other  surgeon  besides  the  attending  surgeon. 
While  pulmonary  cases  are  refused  the  staff  admits  severe,  desperate, 
and  even  hopeless  cases. 

In  a  recent  report  by  two  of  the  members  of  the  staff1  there  are 
histories  of  forty-two  cases  and  illustrations  of  the  methods  of 
treatment ;  but  the  noteworthy  feature  of  the  report  is  the  prominence 
given  to  residence  at  the  seashore  as  the  chief  means  of  cure.  The* 
conclusions  from  seventy-six  histories  which  form  a  basis  of  the  re- 
port are  as  follows : 

(1)  The  seashore  is  the  best  place  for  treating  children  with  tuberculous 
adenitis.  The  children  make  a  better  recovery  here  than  elsewhere.  Those 
with  adenoids  and  enlarged  tonsils  should  be  submitted  to  an  operation  as  a 
start  of  the  cure.     Sea  air  does  not  permit  us  to  dispense  with  this. 

(2)  The  seashore  is  probably  the  best  place  for  children  with  tuberculous 
joints,  provided  they  can  have  there  the  same  skilled  orthopedic  care  as  else- 
where. Their  disease  runs  a  somewhat  milder  and  probably  a  shorter  course, 
and  the  functional  results  are  better  than  those  obtained  elsewhere. 

(3)  Our  results  have  been  largely  due  to  the  careful  attention  (including 
feeding  and  nursing)  which  has  been  given  the  children.  * 

(4)  Our   results   justify  pushing  the  work. 

(5)  A  hospital  such  as  this  does  better  work  than  a  public  hospital  under 
control   of  the  municipality. 

(6)  Many  cases  of  co-called  bone  tuberculosis  are  in  reality  syphilis. 
We  do  not  know  whether  there  is  anything  "  specific  "  about  the  seashore, 


'Leonard  W.  Ely  and  B.  H.  Whitbeck,  Medical  Record,  March  7,  1908. 
See  also  Charlton  Wallace,  Medical  Record,  July  22,  1905 ;  John  Winters 
Brannan,  Trans.  American  Climatological  Association,  1905,  p.  107;  John 
Winters  Brannan,  Trans.  National  Association  for  the  Study  and  Preven- 
tion of  Tuberculosis,  1906.  Roland  Hammond :  Heliotherapy  as  an  Adjunct 
in  the  Treatment  of  Bone  Disease,  Amer.  Journ.  Orthopedic  Surgery,  May 
and  October,  1913. 


46  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

or  whether  children  simply  thrive  better  and  so  overcome  more  quickly  their 
disease.1 

As  to  treatment  other  than  diet  and  fresh  air,  little  need  be  said.  We  use 
plaster  when  we  can  in  preference  to  braces.  In  Pott's  disease  we  use  first 
the  Bradford  frame,  then  plaster  jackets;  in  hip  joints,  the  short  Lorenz 
spica.  In  knee-joint  disease  after  the  acute  stages,  we  also  use  plaster-of- 
Pans.  Patients  with  large  cold  abscesses  are  transferred  to  the  Manhattan 
hospitals,  where  their  abscesses  are  opened,  wiped  out,  and  sewn  up  again 
with  proper   aseptic  precautions. 

On  January  21st  of  the  present  year,  1914,  the  author  revisited 
Sea  Breeze  Hospital,  Coney  Island,  New  York,  in  order  to  see  what 
is  being  accomplished.  Six  cases  of  hip  disease  were  being"  treated 
by  partial  exposure  of  the  body  to  the  sun.  The  patients  were  in 
bed  on  the  balcony  with  the  usual  extension  apparatus  in  place. 
General  exposure,  beginning  with  the  feet  and  gradually  involving 
the  entire  body,  is  not  adopted  at  Sea  Breeze,  as  a  rule,  and  only  the 
area  of  abdomen,  hip  and  thigh  adjacent  to  the  diseased  joint  was 
exposed  to  the  air  and  sun.  Continued  cloudy  and  unfavorable 
weather  had  prevented  much  progress  in  the  newer  patients  who 
were  then  undergoing  treatment ;  others  who  had  been  cured  of 
serious  tuberculous  disease  by  the  open-air  method  had  recently  been 
discharged.  The  fresh-air  system  is,  however,  well  carried  out,  but 
not  upon  the  naked  body  as  in  Switzerland  and  France. 

The  temperature  on  the  open  balcony  next  to  the  wooden  wall  of 
the  building  was  62 °  F.  at  noon  in  the  sun.  It  was  the  first  bright 
day  after  weeks  of  storm  and  cloud.  It  is  probable  that  the  very 
encouraging  experience  of  the  last  two  years  will  lead  to  the  adoption 
of  Rollier's  method  in  all  its  details  as  modified  by  the  less  favorable 
climatic  conditions  of  this  part  of  the  Atlantic  seaboard.2 

Results  at  Sea  Breeze  Hospital  in  the  treatment  of  tuberculosis  of 
the  bones,  joints  and  glands  have  been  so  good  that  the  city  of  New 
York  has  acquired  a  new  location  with  1,000  feet  of  beach  front  on 
what  is  known  as  Rockaway  Point,  ten  miles  beyond  Coney  Island. 
The  plot  runs  back  about  600  feet  to  Jamaica  Bay  and  cost  the  city, 
after  condemnation  proceedings,  $1,250,000.  The  plans  include  an 
arrangement  of  grounds  and  buildings  which  will  involve  a  total 


1  Charlton  Wallace,  M.  D. :  Surgical  Tuberculosis  and  Its  Treatment  (Jour- 
nal of  the  Outdoor  Life,  March,  1913).  This  author,  who  is  Orthopedic 
Surgeon  to  St.  Charles'  Hospital,  Long  Island,  and  the  East  Side  Free 
School  for  Crippled  Children,  New  York,  says :  The  author  is  not  in  a 
position  to  produce  scientific  proof  that  sea  air  is  better  than  country  air, 
but  he  does  believe  such  to  be  the  case,  although  there  are  some  individual 
patients  who  do  better  in  the  country  than  at  the  seashore. 

2  Heliotherapy  is  used  at  the  Crawford  Allen  Hospital,  Rhode  Island. 


NO.    I  AIR    AND    TUBERCULOSIS HINSDALE  47 

outlay  of  $2,500,000,  and  there  will  be  accommodation  for  1,000 
patients  in  the  eight  pavilions.  Contracts  for  two  of  these  pavilions 
have  been  let  and  will  be  paid  for  by  a  fund  raised  by  the  New  York 
Association  for  Improving  the  Condition  of  the  Poor.  The  new- 
hospital  will  be  turned  over  to  the  city  of  New  York  and  will  be  con- 
ducted by  Bellevue  and  Allied  Hospitals.  The  plans  include  an 
immense  playground  running  back  to  Jamaica  Bay  for  the  use  of  the 
public. 

Credit  is  due  to  Dr.  John  Winters  Brannan,  of  New  York,  presi- 
dent of  Bellevue  and  Allied  Hospitals,  for  much  of  the  great  work 
which  has  so  far  taken  about  nine  years  to  accomplish  and  for  which 
America  will  be  justly  proud. 

Encouraged  by  the  success  at  Sea  Breeze,  another  hospital  for 
surgical  tuberculosis  in  children  was  started  six  years  ago  at  Port 
Jefferson,  on  the  north  shore  of  Long  Island,  opposite  the  Sound. 
The  situation  is  said  to  be  ideal.  It  accommodates  two  hundred 
children  and  is  a  handsome  fireproof  structure.  It  is  called  St. 
Charles'  Hospital ;  it  is  under  the  active  care  of  the  "  Daughters 
of  Wisdom,"  a  Roman  Catholic  Society.  The  children,  according 
to  Dr.  Wallace,  receive  every  physical,  mental,  spiritual  and  indus- 
trial care  necessary  to  produce  good  moral  men  and  women.  It  is 
an  active  orthopedic  hospital  admitting  any  deserving  case  and 
keeping  him  there  until  the  lesions  are  healed.  Patients  in  advanced 
stages  of  bone  tuberculosis  are  received  as  well  as  those  with  pul- 
monary complication.  Under  the  good  hygienic  surroundings  at 
St.  Charles'  Hospital,  the  children  have  shown  great  improvement 
in  every  way.  Dr.  Wallace  adds :  "The  removal  of  the  diseased  bone 
with  the  knife  is  no  longer  attempted,  because  such  a  procedure  not 
only  takes  away  the  root  from  which  the  bone  grows,  but  also  fails 
to  eradicate  the  affected  area.  Reliance  must  therefore  be  placed 
on  other  than  cutting  methods  for  local  treatment  of  the  affected 
parts."  Immobilization  by  plaster-of-Paris,  properly  applied  and 
fresh  air  on  the  shore  of  Long  Island  Sound,  conjoined  with  every 
other  hygienic  aid  possible,  constitute  the  line  of  treatment. 

The  New  York  Hospital  for  Ruptured  and  Crippled  has  lately 
removed  to  a  new  site  on  a  hill  near  the  East  River,  where  the 
outdoor  treatment  for  the  tuberculous  cripple  is  carried  out  as  well 
as  it  can  be  in  a  large  city. 

In  England  it  has  long  been  customary  to  send  scrofulous  children 
and  those  with  surgical  tuberculosis  to  the  eastern  and  southeast 
coast.     At  Margate  the  Royal  Sea-Bathing  Hospital,  founded  by 


48  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

Lettsom  and  Latham  in  1791,  is  the  oldest  institution  of  the  kind  in 
Great  Britain,  and  retains  its  pre-eminence.  There  are  similar  insti- 
tutions at  Brighton,  Bournemouth,  Folkestone,  and  Ventnor,  Isle  of 
Wight  (see  plate  12). 

The  impression  prevails  at  present  in  England  that  sea  air  is  the 
best  for  these  cases.  The  bracing  air  suits  them  perfectly  and 
children  with  tuberculous  bones,  joints,  or  glands  can  stand  a 
much  colder  and  fresher  air  than  children  with  pulmonary  disease. 
Sea  air  improves  the  general  health  and  keeps  nutrition  at  the 
highest  level.  Italy  and  France,  however,  take  the  lead  in  seashore 
sanatoria  exclusively  devoted  to  tuberculous  children.  They  have 
been  in  existence  on  the  Italian  shore  at  Viareggio  since  1856,  and 
on  the  French  coast  since  i860,  and  are  conducted  on  a  very  exten- 
sive and  systematic  scale.  The  first  sanatorium  at  Berck-sur-Mer 
was  established  in  i860  by  the  city  of  Paris,  and  is  almost  exclusively 
for  children  suffering  from  tuberculous  disease  of  the  joints,  bones 
and  glands,  and  has  at  present  considerably  over  one  thousand  beds 
and  accommodates  children  from  the  poorest  quarters  of  Paris.1 

Two  private  hospitals  for  similar  cases  are  located  at  Berck- 
Plage.  One  was  founded  by  Baron  Rothschild  and  is  maintained 
by  his  widow  and  contains  600  beds.  Four-fifths  of  the  cases  are 
surgical ;  one-fifth,  medical.2  The  other  is  in  Cazin  Perrochaud  and 
accommodates  200.  At  Pol-sur-Mer  there  is  a  similar  institution 
maintained  by  the  city  of  Lille,  which  is  designed  to  have  900 
beds.8  At  Cannes  there  is  an  excellent  private  institution,  the  Villa 
Santa  Maria,  for  the  "  cure  helio-marine  des  tuberculoses  chirurgi- 
cales  "  under  the  direction  of  D.  A.  Pascal. 

Besides  these  institutions  for  surgical  tuberculosis  there  are  others 
which  are  intended  mainly  for  pulmonary  tuberculosis.  These  are 
located  at  Hendaye,  Ormesson,  Villiers-sur-Marne  and  Noisy  le 
Grand.  There  are  now  fifteen  sanatoria  on  the  French  coast  open 
throughout  the  year  and,  in  addition,  a  number  open  for  only  a 
part  of  the  year,  containing  in  all  over  four  thousand  beds.  In  1904 
there  were  twenty-three  Italian  hospitals  distributed  along  the  Medi- 
terranean and  Adriatic  shores  of  Italy,  with  over  ten  thousand  beds. 


1  See  article  by  the  author  on  "  The  Treatment  of  Surgical  Tuberculosis," 
etc.    Interstate  Medical  Journal,  St.  Louis,  March,  1914. 

2  See  article  by  Douglas  C.  McMurtrie,  Boston  Medical  and  Surgical  Jour- 
nal,  Jan.   2,    1913. 

3  See  article  by  John  W.  Brannan,  loc.  cit. 


Ul       • 

i  a 

o  >, 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    13 


WEST  GALLERIES,   MARITIME  HOSPITAL  FOR   TUBERCULOSIS,  BERCK-PLAGE,  FRANCE.     300  BEDS 


SOUTH   GALLERIES,   MARITIME  HOSPITAL   FOR  TUBERCULOSIS,   BERCK-PLAGE,  FRANCE.     216  BEDS 


NO.    1  AIR    AND   TUBERCULOSIS — HINSDALE  49 

These  hospitals  are  said  to  be  closed  in  winter.  (Brannan.)  Every 
other  country  in  Europe,  with  the  exception  of  Turkey  and  Greece, 
has  one  or  more  seashore  sanatoria  for  tuberculous  children,  so  that 
there  are  as  many  as  seventy-five  such  hospitals  on  the  shores  of 
Europe.  The  Argentine  Republic  has  two  seashore  sanatoria,  one 
established  twenty-three  years  ago  with  three  hundred  beds  and  a 
new  one  with  five  hundred  beds. 

The  plan  of  treatment  at  all  these  institutions  is  very  simple  and 
ought  to  have  been  carried  out  on  this  side  of  the  Atlantic  long  ago. 
The  brilliant  experience  at  Sea  Breeze,  Coney  Island,  is  simply  due 
to  a  repetition  of  the  methods  adopted  for  decades  in  France  and 
England.  The  regime  at  all  these  sanatoria  is  about  the  same.  The 
patients  are  kept  out  of  doors  all  day  on  the  beach  or  on  verandas, 
which  are  covered  but  are  open  on  the  front  and  sides.  Four  meals 
a  day  with  unlimited  milk  are  provided.  All  through  the  winter 
the  children  occupy  themselves  on  the  grounds  or  on  the  beach  ;  those 
confined  to  bed  are  on  the  open  porches  enjoying  the  sunshine  and 
the  sea  air,  the  "best  tonics  in  the  world,  and  developing  a  ruddy 
color  and  better  general  circulation  than  they  have  ever  known. 
Their  warm  hands  in  the  coldest  winter  weather  is  the  wonder  of 
all  who  visit  them.  At  night  the  windows  are  wide  open  and  the  air 
has  practically  the  same  temperature  as  at  any  point  on  the  coast, 
varying  from  120  to  400  F.  If  the  snow  drifts  in  at  night,  as  some- 
times happens,  nobody  seems  to  be  the  worse.  The  windows  are, 
however,  closed  for  a  half  hour  morning  and  evening  while  the  chil- 
dren are  being  washed  and  dressed. 

The  surgeons  at  Berck-Plage,  although  engaged  in  active  ortho- 
pedic work,  are  all  firmly  convinced  that  residence  at  the  seashore, 
with  the  greater  part  of  the  twenty- four  hours  spent  in  the  open  air, 
does  more  for  the  children  than  could  be  accomplished  even  in  the 
best  appointed  hospitals  in  the  cities.1  One  of  the  surgeons  at  Mar- 
gate, after  fifteen  years  of  constant  work  in  the  wards,  states  his 
opinion  that  the  knife  plays  a  very  secondary  part  to  climatic  and 
general  influences. 

For  an  institution  of  this  kind  to  attain  the  highest  efficiency  one 
thing  seems  plain ;  the  patients  must  be  admitted  at  a  very  early  age, 
not  from  six  years  old  and  upwards,  but  as  early  as  two  years  of 
age.  In  this  respect  the  French  and  American  sanatoria  have  the 
advantage  of  the  English.    The  point  has  been  made  that  at  six  years 


1  Each  year  during  the  early  part  of  August  vacation  clinics  are  held,  which 
are  attended  by  large  numbers  of  French  and  foreign  physicians. 


50  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

of  age  a  child  with  tuberculous  disease  is  often  past  cure.  Much 
can  be  done  with  a  tuberculous  case  if  "  caught  young." 

After  serious  operations,  the  surgeons  at  the  seaside  sanatoria  note 
that  progress  is  much  more  rapid  when  patients  can  live  in  the  open 
air  and  the  practical  point  has  been  discovered  that  subsequent  dress- 
ings of  a  much  more  simple  character  are  permissible  under  the  open 
air  regime.  For  instance,  in  Metropolitan  hospitals  the  practice  of 
packing  and  draining  wounds  has  untold  terrors  for  the  unfortunate 
patients.  Dr.  Charlton  Wallace  found  that  at  "  Sea  Breeze  "  tuber- 
culous sinuses  heal  more  rapidly  and  permanently  when  all  packing 
and  drainage  are  omitted  and  only  a  sterile  absorbent  dressing  is 
applied.  As  the  general  instability  of  these  patients  is  such  as  to 
cause  them  almost  to  collapse  at  the  thought  of  having  their  wounds 
probed  and  packed,  it  led  him  to  believe  that  they  would  gain 
strength  and  local  resistance  if  they  were  not  nervously  upset  at  the 
time  of  each  dressing.  In  the  beginning,  in  order  to  ascertain 
whether  there  would  be  full  drainage  comparisons  were  made  of 
the  amount  of  discharge,  with  and  without  the  full  dressing,  and  as 
there  was  no  diminution  he  concluded  that  packing  or  tubing  was  not 
essential  to  drainage.  Not  only  was  the  danger  of  infection  less, 
no  infected  wound  being  observed,  but  he  found  that  no  sinus  healed 
which  still  contained  pus.  This  certainly  simplifies  the  treatment  of 
surgical  wounds  and  the  credit  is  given  to  the  favorable  atmospheric 
conditions. 

At  Sea  Breeze  the  children  receive  from  one  to  two  hours  instruc- 
tion daily,  the  teachers  being  furnished  by  the  Brooklyn  Board  of 
Education.  It  has  been  noted  that  the  educational  training  given  at 
this  Sea  Breeze  Hospital  has  a  most  happy  effect  on  the  morals  of 
the  patients  and  at  this  early  age  much  more  can  be  accomplished 
in  combating  vice  and  ignorance,  which  constitute  the  greatest  ob- 
stacles in  dealing  with  the  tuberculosis  problem. 

(For  open  air  schools  for  tuberculous  children,  Waldschule,  etc., 
see  pp.  103-107). 

In  estimating  the  value  of  sea  air  in  non-pulmonary  tuberculosis 
in  children,  we  naturally  look  to  France  for  some  data  based  on  the 
enormous  experience  now  extending  over  a  period  of  nearly  fifty 
years.  During  the  last  twenty  years  in  France  alone  60,000  children 
have  been  treated  in  these  sanatoria  and  Dr.  Brannan  is  authority  for 
the  following  statement : 

Cures,  59  per  cent.     Decidedly  improved.  .25  per  cent 

Total    of    favorable    results     84  per  cent 

Cures    in    Pott's    Disease    32  per  cent 

Cures  in  glandular  tuberculosis  74  per  cent 


SMITHSONIAN    MISCELLANEOUS   COLLECTIONS 


VOL.    63,    NO.    1,    PL.    14 


HELIOTHERAPY.     VIEW    OF    THE     SOUTH     GALLERIES    OF    THE    MARINE    HOSPITAL,   BERCK-PLAGE, 
FRANCE.     THE  CHILDREN   ARE   EXPOSED  ALL  DAY  NAKED  TO  THE  SUN 


SEA   BREEZE  HOSPITAL,  SEA  GATE,   NEW  YORK.     OPEN   AIR  SCHOOL 
Courtesy  of  Dr.  J.  W.  Brannan 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63.    NO      t,    PL.    15 


HELIOTHERAPY.  SEA  BREEZE  HOSPITAL,  SEA  GATE,  NEW  YORK, 
MARCH  18,  1913.  CURED  CASE  OF  TUBERCULOSIS  OF  THE  KNEE.  NO 
SINUS. 

Courtesy  of  Dr.  Brannan 


HELIOTHERAPY  AT  SEA  BREEZE  HOSPITAL,  SEA  GATE,  NEW  YORK,  OCTOBER,  1912.  CHILDREN 
ON  THE  BEACH.  CURED  CASES  OF  TUBERCULOSIS  OF  THE  WRIST  AND  ANKLE.  THERE  WERE 
OPEN  SINUSES   IN   EACH  CASE. 


NO.    I  AIR    AND   TUBERCULOSIS — HINSDALE  51 

These  results  of  the  treatment  of  surgical  tuberculosis  at  seashore 
sanatoria  are  much  more  favorable  than  in  the  case  of  pulmonary 
tuberculosis,  in  adults,  in  corresponding  localities  (see  pp.  71-73) - 

Nevertheless,  the  Department  of  Public  Charities  of  the  City  of 
New  York  has  just  built  and  equipped  at  an  expense  of  £3,500,000, 
a  new  hospital  for  adults  having  pulmonary  tuberculosis  in  the  sec- 
ond or  third  stage.  The  site  selected  is  on  the  highest  point  of  Staten 
Island  in  New  York  Bay,  400  feet  above  tide  and  only  five  miles  from 


1  See  R.  Russell,  M.  D. :  Glandular  Tabes,  or  the  Use  of  Sea  Water  in 
Diseases   of  the   Glands.     London,    1750. 

Ebenezer  Gilchrist,  M.  D. :  The  Use  of  Sea  Voyages  in  Medicine.  Lon- 
don,   1771. 

Albert  L.  Gihon,  M.  D.,  U.  S.  N. :  The  Therapy  of  Ocean  Climate  (Trans. 
Amer.    Climat.   Ass.,    1889,   p.   50). 

M.  Charteris,  M.  D. :  Ocean  Climate  (Trans.  Amer.  Climat.  Ass.,  1890,  p. 
278). 

Wm.  Ewart,  M.  D.,  F.  R.  C.  P. :  The  Present  Position  of  the  Treatment 
of  Tuberculosis  by  Marine  Climates  (Journ.  Balneology  and  Climatology, 
July,    1907). 

W.  S.  Wilson :    The  Ocean  as  a  Health  Resort,  London,  1880. 

J.  V.  Shoemaker,  M.  D. :  Ocean  Travel  for  Health  and  Disease  (The  Lancet, 
July  23,   30,    1892). 

Hughes  Bennett,  M.  D. :  Life  at  Sea  Medically  Considered  (Medical  Times 
and  Gazette,  Vol.  1,  1884,  p.  244). 

Thomas  B.  Peacock,  M.  D. :  Beneficial  Influence  of  Sea  Voyages  in  Some 
Forms  of  Disease   (Medical  Times  and  Gazette,  Vol.  2,  1873,  p.  687). 

John  L.  Adams :  Report  of  17  cases  of  Surgical  Tuberculosis  in  Children 
(Boston  Medical  and  Surgical  Journal.  1906,  Vol.   154,  p.   17). 

A.  Crosbee  Dixey,  M.  R.  C.  P.:    Edinb.  Lancet,  Vol.  2,  1888,  p.  264. 

Boardman  Reed :  Effects  of  Sea  Air  Upon  Diseases  of  the  Respiratory 
Organs    (Trans.  Amer.   Climat.  Ass.,  Vol.    1,   1884,   p.  51). 

D'Espine,  of  Geneva.  International  Congress  on  Tuberculosis,  Paris,  Octo- 
ber,   1905. 

Armaingaud,  of  Bordeaux :  International  Congress  on  Tuberculosis,  Paris, 
1905. 

Guy  Hinsdale,  M.  D. :  Treatment  of  Surgical  Tuberculosis  at  the  French 
Marine  Hospitals  and  Alpine  Sanatoria  (Interstate  Medical  Journal,  St.  Louis, 
March,  1914). 

Trans.  Congres  de  L'Association  Internationale  de  Thalassotherapie, 
Cannes,  April,  1914. 

See  also  Willy  Meyer :  Open-Air  and  Hyperemic  Treatment  as  Pow- 
erful Aids  in  the  Management  of  Complicated  Surgical  Tuberculosis  in 
Adults  (Trans.  Sixth  International  Congress  on  Tuberculosis,  Washington, 
1908,   Vol.   2,   twenty   illustrations). 

See  also  "  Open  Air  Treatment  of  Tuberculosis,"  by  the  late  Dr.  DeForest 
Willard,  ibid.,  page  257.  Also  Trans.  Amer.  Orthopedic  Ass.,  1898.  Shacks, 
bungalows,   sleeping   tents,    sanatoria   and   day   camps    are   discussed. 


52  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

the  ocean.     This  new  addition  to  New  York's  equipment  has  one 
thousand  beds  and  is  called  the  "  Sea  View  Hospital." 

At  the  Second  Annual  Meeting  of  the  National  Association  for  the 
Study  and  Prevention  of  Tuberculosis  held  in  Washington  in  1906, 
the  following  resolution  was  offered  by  Dr.  John  W.  Brannan  and 
unanimously  adopted : 

Whereas,  Recent  experience  in  Europe  and  in  this  country  has  shown  that 
out-door  life  in  pure  air  has  the  same  curative  effect  in  surgical  tuberculosis 
as   in   tuberculosis   of   the  lungs,   therefore,  be   it 

Resolved,  That  in  the  opinion  of  members  of  this  Association  hospitals 
and  sanatoria  should  be  established  outside  of  cities  either  in  the  country  or 
on  the  seashore  for  the  treatment  from  its  incipiency,  of  tuberculosis  of 
bones,  joints,  and  glands  in  children. 

SEACOAST   AND  FOGS 

Marine  climates  naturally  include  the  strictly  ocean  climate  and 
that  of  the  seacoast.  In  the  former  sea  air  comes  from  every  point 
of  the  compass.  It  is  always  moist  and  it  is  the  most  equable  air  that 
blows ;  it  is  of  infinite  variety  from  the  dead  calm  of  the  doldrums  to 
the  fierce  gales  of  the  North  Atlantic. 

The  atmosphere  of  the  seacoast  is  naturally  modified  at  times  by 
continental  influences.  Indeed  the  characteristic  "  sea  breeze  "  which 
springs  up  in  the  morning  and  subsides  toward  sun-down  is  brought 
about  by  the  ascent  of  heated  air  back  of  the  coast.  The  hotter  the 
interior  and  the  more  rapidly  this  air  ascends  the  stronger  is  the 
sea  breeze  which  rushes  shoreward  from  the  ocean  and  penetrates 
for  fifty  or  a  hundred  miles  the  adjoining  country. 

But  under  other  conditions  land  breezes  occur  and  bring  to  the 
shore  the  Continental  atmosphere  of  a  totally  different  type.  These 
atmospheric  conflicts  between  sea  and  land  involve  most  interesting 
meteorological  problems ;  they  tend  to  lessen  the  equability  of  the 
purely  marine  or  oceanic  climate.  Freezing  weather  is  the  product 
of  the  Continent  and  the  descent  of  cold  waves  from  the  interior ; 
it  brings  to  our  northern  seacoast  frost  and  snow  for  a  time,  and 
never  trespassing  far  upon  the  high  seas.  The  seacoast  has  thus  a 
mixture  of  two  climates,  but  the  sea  air  predominates  and  is  never 
absent  very  long. 

There  are  well-known  places  in  America  and  in  the  British  Islands 
where  the  sea  breeze  greatly  predominates ;  Nova  Scotia,  Cape  Cod, 
and  Cape  May  in  the  United  States ;  Land's  End  and  the  Cornish 
Coast  in  England  are  cases  in  point.  In  such  exposed  situations  the 
air  is  generally  poorly  adapted  to  the  tuberculous  patient.     The  air 


SMITHSONIAN    MI8CE LLANEOUS    COLLECTIONS 


VOL.    63      NO.    1,    PL.     16 


SEA   BREEZE   HOSPITAL,   SEAGATE,  NEW  YORK.     TREATMENT  OF  POTT'S   DISEASE  OF  THE  SPINE 

WITH   PLASTER  JACKETS  AND  HELIOTHERAPY 

Courtesy  of  Dr.  J.  W.  Brannan 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,     NO.     1,     PL.     17 


liii»Kaa 


FIG.   1.     HELIOTHERAPY  FOR  SURGICAL  TUBERCULOSIS.     DR.   ROLLIER'S  SANATORIUM, 
LEYSIN,  SWITZERLAND.      DORSAL   EXPOSURE 


FIG.  2.      HELIOTHERAPY   FOR   SURGICAL  TUBERCULOSIS.      DR.   ROLLIER'S  SANATORIUM. 
From  the  author's  article  in   Interstate  Medical  Journal,  March,  1914 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  53 

is  said  to  be  "  too  strong  "  and  certainly  for  an  all-the-year-round  resi- 
dence the  capes  and  headlands  are  too  much  at  the  mercy  of  high 
winds  which  render  out-door  life  disagreeable.  About  Cape  Cod, 
Nantucket,  and  Martha's  Vineyard  there  is  a  peculiar  liability  to  fog 
which  is  as  unwelcome  to  the  consumptive  as  it  is  to  the  mariner. 

The  author  has  had  experience  with  the  fogs  in  these  waters  and 
considers  it  one  of  the  great  drawbacks  to  an  otherwise  agreeable 
climate.  The  summer  and  early  autumn  fogs  of  the  eastern  Maine 
coast  and  of  the  Bay  of  Fundy  and  Nova  Scotia  are  worse  in  their 
chilly  and  penetrating  qualities.  The  towns  of  Massachusetts  on  or 
near  the  seacoast  seem  to  have  somewhat  more  tuberculosis  than 
those  of  the  interior. 

Deaths    from    Pulmonary    Tuberculosis   in    Massachusetts    per    100,000 

Population 

Five  Maritime  Towns  Five  Inland  Towns 

1905  1908-1912  1905  1908-1912 

Boston 224  155          Pittsfield    168  98 

Salem   154  111          Springfield 125  89 

New  Bedford 164  124          Chicopee    125  109 

Newburyport    181  131          Holyoke   154  131 

Plymouth  162  90          North  Adams    81  98 

Average    177  122  Average   131  105 

Mr.  Hiram  F.  Mills,  of  the  Massachusetts  State  Board  of  Health, 
has  lately  published  a  most  painstaking  analysis  of  the  mortality 
from  tuberculosis  in  all  the  towns  and  cities  of  that  state.1 

He  shows  that  there  are  sixty  cities  and  towns  bordering  on  the 
sea  having  a  total  population  of  about  one-third  of  the  entire  state, 
or  1,293,625,  in  which  the  average  death-rate  per  100,000  for  the  five 
years,  1908-1912,  was  135.  During  this  period  the  rate  for  the  entire 
state  was  131.  Omitting  Boston,  which  has  peculiar  conditions, 
from  both  calculations  the  rate  was  in  for  the  remaining  59  mari- 
time towns  and  cities  against  124  for  the  remainder  of  the  State. 
This  throws  the  balance  in  favor  of  the  seaboard.  It  should  be 
noted  that  all  the  small  and  sparsely  settled  towns  have  low  rates 
in  almost  regular  gradation  when  compared  with  more  and  more 
populated  districts. 

Boston  has  had  a  noteworthy  decrease  in  its  tuberculosis  death 
rate  as  shown  by  the  following  figures  representing  the  rate  for  the 
last  five  years,  namely,  271,  283,  254,  176,  182,  or  a  decrease  of  one- 
third  in  five  years.    There  are  sixteen  small  towns  having  an  aggre- 


1  Address  to  the  State  Inspectors  of  Massachusetts,  November  3,  1913. 
6    - 


54  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

gate  population  of  5,540,  in  which  there  have  been  no  deaths  in  all 
of  the  five  years. 

The  map  shows  several  inland  towns  with  a  large  death  rate  ow- 
ing to  the  presence  of  tuberculosis  hospitals,  asylums,  and  other  insti- 
tutions. These  are  marked  with  an  H  (not  readily  seen  in  the 
reduced  map)  and  include  Rutland,  Sharon,  Lakeville,  Bridgewater, 
North  Reading,  Medfield,  Westborough,  Westfield,  Taunton,  Dan- 
vers,  and  Monson. 

As  Mr.  Mills  says : 

Forty  years  ago  the  death  rate  from  consumption  in  Massachusetts  was  three 
times  as  great  as  it  is  now ;  thirteen  years  ago  it  had  been  reduced  one-half  in 
the  previous  forty  years  ;  to-day  it  has  been  reduced  one-half  in  the  past  twenty 
years.  There  is  no  other  State  in  the  Union,  in  which  records  have  been 
kept,  where  the  reduction  has  been  so  much.  From  1885  to  1909  it  was  more 
than  twice  as  great  as  in  England,  Scotland,  Ireland,  The  Netherlands,  Bel- 
gium, Switzerland  and  Italy.  The  reduction  is  Prussia  was  90  per  cent  of 
that  in  Massachusetts  and  that  in  Austria  only  57  per  cent.  The  registration 
system  in  Massachusetts  is  of  the  highest  grade  and  in  no  other  State  or 
country  of  the  world  has  such  effective  work  been  done  and  so  much  accom- 
plished in  reducing  the  death  rate  from  tuberculosis  as  in  that  Commonwealth. 

FOGS  ON   THE  PACIFIC   COAST 

It  is  this  element  of  fog  which  renders  so  much  of  the  Pacific 
coast  of  the  United  States  unsuitable  for  tuberculous  patients.  The 
morning  fogs  are  conspicuous  features  of  the  climate  and  are 
acknowledged  sources  of  danger  to  tuberculous  cases.  They  pene- 
trate as  far  as  Los  Angeles  and  Pasadena  in  the  south,  some  eighteen 
miles  from  the  coast ;  they  are  common  in  San  Francisco,  and  are 
carried  by  ocean  atmospheric  currents  through  the  Golden  Gate, 
sweeping  the  bay  and  up  the  Sacramento  and  San  Joaquin  valleys. 

There  are  portions  of  the  California  coast,  as  for  example  in  the 
neighborhood  of  Santa  Barbara,  where  the  mountains  are  near  the 
shore ;  and  beyond  the  mountains  are  deserts  and  necessarily  an 
exceedingly  dry  atmosphere.  The  night  air  from  the  mountains 
brings  with  it  a  dry  Continental  quality ;  the  morning  breezes  bring 
a  more  humid  air  and  possibly  fog.  In  such  localities  fog  is  quickly 
scattered  by  the  sun's  heat  and  never  penetrates  very  far  inland.  A 
suitable  residence  for  tuberculous  patients  on  the  Pacific  coast,  as 
every  native  knows,  is  not  found  on  the  shore  line  but  at  some  eleva- 
tion above  the  sea  fairly  well  up  on  the  hillsides  or  in  well-situated 
valleys,  like  the  Montecito  Valley,  where  the  dryer  air  of  the  interior 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


■n 


STATE  BOARD  OF  HEALTH 

MAP  OF  THE 

STATE  OF  MASSACHUSETTS 

DEATHS  FROM  CONSUMPTION 

scale  or  MiLeis 


VOL.    63,    NO.    1,    PL.    IS 


\  If?-  ;'i 


NO.    I  \IK    AND    TUBERCULOSIS — HINSDALE  55 

checks  the  advent  of  fog  and  where  the  early  morning  hours  are  as 
bright  and  dry  as  the  afternoons.1 

RADIATION    FOGS 

Fogs  are  born  of  the  sea  and  of  the  land.  The  sea  fog  is  obviously 
purer  and  less  injurious  than  the  smoke-laden  fog  of  cities.  There- 
are  fogs  and  fogs;  "dry"  fogs  and  "wet"  fogs;  the  fogs  of  the 
coast  and  the  fogs  of  mountain  valleys  and  river  courses ;  but  rarely 
of  the  plains.  Radiation  fogs  are  different  from  sea  fogs  :  in  dry 
weather,  on  a  cold  still  night  when  the  lowest  stratum  of  air  is  rap- 
idly cooled  by  contact  with  the  cold  radiating  earth,  the  watery  vapor 
is  precipitated  as  minute  globules.  The  colder  the  ground  or  the 
deeper  and  colder  the  water  on  which  fog  rests,  the  more  persist- 
ent is  the  fog ;  but  as  the  sun  warms  the  watery  particles  and  over- 
comes the  heat  lost  by  radiation,  the  fog  lifts  and  floats  upward.  It 
is  bound  to  lift  as  its  specific  gravity  diminishes.  Slopes  of  hills, 
especially  their  southern  sides,  some  hundreds  of  feet  above  the  low- 
land or  seashore,  are  thus  comparatively  free  from  these  fogs  and 
are  much  drier  and  warmer  than  lower  places  in  the  neighborhood. 
Such  locations  are  far  preferable  to  those  of  lower  altitude.  ( Rus- 
sell.) 

FOGS  IN  THE  MOUNTAINS 

And  here  we  see  how  local  geographic  conditions  modify  the 
whole  aspect  of  the  question.  On  the  North  Atlantic  Coast  of  the 
United  States  there  are  no  mountain  ranges ;  one  cannot  get  away 
from  the  fogs  if  he  would  ;  while  on  the  Pacific  Coast,  the  mountains 
and  their  foot  hills  are  comparatively  near  and  one  can  be  in  full 
view  of  the  seashore  and  yet  be  above  the  fog  line. 

At  Santa  Barbara,  one  of  the  favorite  California  resorts  for  tuber- 
culous patients,  fogs  occur  frequently  from  May  until  October,  but 
are  comparatively  rare  at  other  times.  Dr.  William  H.  Flint,  who 
practiced  there  for  thirteen  years,  says  that  the  fogs  creep  in  from 
the  sea  in  the  late  afternoon,  in  the  evening,  or  in  the  early  morn- 
ing, disappearing  at  an  uncertain  hour  the  following  forenoon.  Occa- 
sionally fogs  will  persist  all  day  and  for  a  number  of  days  consecu- 
tively. In  May  and  June,  1903,  a  foggy  period  continued  for 
seventeen  days.2 


1  See   A.    G.   McAdie :    The    Sun   as   a   Fog    Producer,    Monthly    Weather 
Review,  Washington,    1913    (778-779). 

2  Trans.  Amer.   Climat.   Ass.,    1904,   p.  20. 


56  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

The  late  Dr.  C.  H.  .Alden,  Asst.  Surgeon  General,  U.  S.  A.,  who 
passed  his  later  years,  and  died  of  tuberculosis,  in  Pasadena,  Cali- 
fornia,  says; 

The  climate  of  Southern  California  is  not  a  dry  one,  as  some  suppose.  As  this 
region  lies  along  the  coast,  and  its  most  frequented  portions  are  nowhere  very- 
distant  from  the  water,  the  climate  cannot  be  dry.  The  humidity  lessens  as  one 
goes  inland,  but  is  always  considerable,  except  in  the  uninhabited  desert.  The 
fogs  which,  in  the  absence  of  much  rain,  are  a  large  factor  in  sustaining 
vegetation,  penetrate  many  miles  from  the  sea  and  add  to  the  humidity. 
The  fact  that  the  humidity  is  not  favorable  for  pulmonary  tuberculosis 
which  is  at  all  advanced  is  evidently  not  appreciated  as  it  should  be. 
[Italics,  author's.] 

Even  as  far  as  Redlands,  over  fifty  miles  from  the  coast,  according 
to  General  Alden,  who  lived  there  for  two  winters,  "  fogs  come  up 
from  the  sea  during  the  spring,  but  they  are  shorn  of  most  of  their 
moisture."  Nevertheless,  Redlands,  from  its  comparative  dryness, 
is  a  favorite  place  in  winter  for  patients  with  pulmonary  tuberculosis 
and  they  no  doubt  do  better  there  than  at  Los  Angeles,  Pasadena,  or 
at  resorts  directly  on  the  coast.  General  Alden's  conclusion  is  that 
while  the  mild  temperatures  and  continuous  sunshine  of  this  region 
are  favorable  for  the  aged  and  the  feeble  from  many  causes,  need- 
ing an  out-door  life,  the  warmth  and  moisture  are  unfavorable  for 
cases  of  pulmonary  tuberculosis  that  are  at  all  advanced. 

In  June,  1902,  the  author  traveled  through  the  mountains  and  vis- 
ited the  principal  resorts  throughout  California.  The  sea  air  with  its 
frequent  accompaniment  of  fog  seemed  to  him  too  strong  or  fresh 
for  tuberculous  patients.  North  of  Santa  Barbara  or  Monterey  the 
sea  air  is  certainly  cold  and  harsh  during  most  of  the  year  and, 
wherever  it  penetrates,  tuberculous  patients  feel  worse.  This  is  par- 
ticularly true  of  the  neighborhood  of  San  Francisco.  From  the 
summit  of  Mt.  Tamalpais,  elevation  2,375  feet>  on  almost  any  sum- 
mer afternoon  fog  can  be  seen  driving  in  from  the  Pacific  and 
spreading  over  San  Francisco  Bay.  As  the  sun  descends  the  tem- 
perature of  the  air  drops,  so  that  saturation  is  reached.  Fog  results. 
Now  on  the  southern  California  coast  the  cold,  ocean  atmospheric 
currents  contain  much  less  actual  moisture  than  the  warm,  clear  air 
on  shore  and  the  resultant  mixture  will  now  contain  less  water  than 
the  warm  air  did  before  and  hence  it  is  claimed  with  reason  that 
notwithstanding  the  dripping  roofs  and  wet  pavements,  there  is  less 
absolute  moisture  in  the  air  than  before  the  fog  appeared. 

We  did  not  find  the  California  fog  either  so  cold  or  chilling  as  we 
have  observed  it  on  the  extreme  eastern  coast  of  Maine ;  nor  is  it  so 


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NO.    I  AIR   AND    TUBERCULOSIS — HINSDALE  57 

depressing  and  relaxing  as  the  heavy  misty  weather  observed  in 
central  and  western  Virginia  mountain  valleys  during  the  rains  of 
early  summer  and  autumn,  certainly  not  so  depressing  as  the  relax- 
ing moisture  of  the  tropics.  The  California  fogs  have  been  likened 
to  the  Scotch  mist.  They  never  deter  the  fishermen  from  curing 
their  fish  on  their  racks  along  the  seashore.  Raisins  and  other  fruit 
are  dried  in  the  open  fields  and  residents  claim  that  during  the 
rainiest  weather  nothing  molds  or  rots.     (P.  C.  Remondino.) 

Mr.  Ford  A.  Carpenter,  of  the  U.  S.  Weather  Bureau,  has  published 
an  interesting  book,  in  which  he  gives  a  lucid  description  of  the  fogs 
of  the  Pacific  Coast.1  He  shows  that  on  that  coast  the  maximum 
fog  is  reached  in  San  Francisco,  with  moderately  high  averages 
north  to  the  Canadian  boundary  and  decreasing  in  frequency  and 
duration  with  the  latitude,  San  Diego  having  the  least  on  the  coast. 
He  says  that  daylight  fogs  are  practically  unknown  in  San  Diego. 
A  "  day  with  fog  "  is  one  on  which  there  is  one  hour  or  more  of 
fog  dense  enough  to  obscure  objects  one  thousand  feet  distant.  At 
San  Diego  the  hours  of  greatest  frequency  were  between  eleven  at 
night  and  six  in  the  morning.  Mr.  Carpenter  notes  the  beneficial 
effect  of  California  fogs  and  says  that  it  is  impossible  to  measure 
accurately  the  amount  of  moisture  conveyed  by  fog.  There  is  no 
doubt  that  over  a  region  covered  by  vegetation  exposing  a  natural 
condensing  surface,  such  as  eucalyptus,  palm,  iceplant,  etc.,  not  less 
than  a  ton  of  water  to  the  acre  is  thus  distributed  during  the  preva- 
lence of  every  dense  fog.    It  also  checks  evaporation. 

"  It  is  not  fog  in  the  generally  accepted  meaning,  for  this  '  light 
veil '  is  neither  cold  nor  excessively  moisture-laden.  Neither  is  it 
high,  for  its  altitude  is  less  than  a  thousand  feet.  To  one  who  has 
spent  a  few  weeks  of  spring,  summer  or  fall  in  southern  California, 
the  picturesque  description  of  the  musical  Spanish  el  velo  is  quickly 
recognized  as  both  expressive  and  truthful."  "  El  velo  de  la  lus  "  : 
"  the  veil  that  hides  the  light."  "  Velo  qui  cubre  la  lus  del  so  " : 
"The  veil  which  shades  (covers)  the  light  of  the  Sun."  "El  velo 
de  la  manana  "  :     "  The  veil  of  the  morning." 

There  is  probably  no  place  on  the  entire  coast  line  of  the  United 
States  that  offers  so  many  climatic  advantages  for  tuberculous 
patient  as  San  Diego  and  its  attractive  neighbor,  Coronado. 

It  is  a  mistake  to  believe  that  because  there  is  fog,  the  humidity 
is  necessarily  high  during  its  presence.    The  United  States  Weather 


1  The  climate  and  weather  of  San  Diego,  California.    San  Diego,  1913.    See 
Review  in  Journ.  Royal  Meteorological  Society,  Jan.,  1914. 


58  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

Bureau  has  taken  pains  to  determine  the  relative  humidity  during 
fog's  observed  during  ten  years  at  Chicago  on  Lake  Michigan.  Ob- 
servations were  made  on  118  foggy  days  by  Dr.  Frankenfield,  whose 
results  are  given  as  follows : 

Relative  humidity  90  per  cent   (or  more)  in  75  per  cent  of  days. 
Relative  humidity  80  to  90  per  cent  in   13   per  cent  of  days. 
Relative  humidity  below  80  per  cent  in  12  per  cent  of  days. 

The  observer  noted  dense  fog  on  one  occasion  when  the  relative 
humidity  was  as  low  as  52  per  cent ;  on  another,  when  it  was  58  per 
cent. 

The  Pacific  coast,  as  a  whole,  is  much  foggier  than  the  Atlantic 
coast,  because  the  winds  on  the  Atlantic  are  mostly  off-shore  and 
consequently  carry  less  moisture  than  the  westerly  on-shore  winds  of 
the  Pacific. 

In  the  interior  of  the  United  States,  especially  the  western  half, 
the  average  number  of  foggy  days  per  year  is  less  than  ten  each 
year ;  in  the  Lake  region  the  number  rises  to  fifteen  or  twenty  per 
annum.  In  isolated  localities,  local  conditions  increase  this  number 
greatly. 

At  Colorado  Springs  genuine  fogs  occur,  sometimes  very  dense 
and  lasting  all  day,  but  they  are  uncommon  and  scarcely  worth 
mentioning  were  not  their  existence  so  often  denied.     (Ely.) 

In  the  Adirondack  Mountains  fogs  and  mists  are  not  uncommon 
along  the  rivers  and  on  the  lake  shores  in  the  early  morning  in  the 
summer  and  autumn.  They  are  examples  of  the  radiation  fogs 
already  referred  to  and,  like  dew  and  frost,  they  are  associated  with 
clear  weather.  The  presence  of  a  light  fog  over  an  Adirondack  lake 
in  the  early  morning  foretells  a  bright,  sunny,  warm  day. 

Fogs  are  not  at  all  unusual  in  the  Alleghany  and  Blue  Ridge 
Mountains.  They  follow  river  courses  and  settle  in  low  valleys. 
The  humidity  attendant  on  the  melting  of  snow  or  during  the  rains 
of  early  summer  or  autumn  is  not  so  readily  exchanged  for  dryer 
air  in  the  long  narrow  valleys  as  at  the  seaboard.  In  many  localities 
the  high  ridges  on  either  side  shut  out  the  direct  rays  of  sunlight 
for  several  hours ;  while  at"  the  seaboard  there  are  no  such  natural 
barriers. 

At  some  of  the  higher  elevations  in  the  Blue  Ridge  Mountains 
of  Pennsylvania,  fog  is  noted  during  the  summer  and  autumn.  One 
observer,  himself  a  tuberculous  patient,  recorded  at  Mount  Pocono, 
in  Monroe  County,  Pa.,  elevation  2,000  feet,  fifteen  days  with  fog 
part  of  the  day,  usually  early  morning,  and  seven  with  fog  all  day, 


CO   £ 
O  "S 


u 


■SMITHSONIAN     MISCELLANEOUS    COLLECTIONS 


VOL.    6'i.    NO.    1,    PL.    23 


FIG.    1.      RUTLAND,    MASSACHUSETTS,   STATE   HOSPITAL   FOR   CONSUMPTIVES 


DAY  CAMP   FOR  TUBERCULOUS    PATIENTS,    HOLYOKE,    MASS. 


tr   o 


NO.    I  AIR    AND    TUBERCULOSIS — HINSDALE  59 

between  June  I  and  December  i.  But  this  patient  adds  the  signifi- 
cant remark :  "  However,  it  seems  ridiculous  for  me  to  find  fault 
with  Mount  Pocono  when  I  did  so  well  there.  My  cough  and  expec- 
toration decreased  considerably ;  I  gained  five  pounds  and  grew 
somewhat  stronger.''1 

At  Rutland,  Massachusetts,  the  site  of  the  Massachusetts  State 
Sanatorium,  there  were  24  days  with  fog  for  the  year  ending  Novem- 
ber 30,  1907.  Nevertheless,  out  of  4,334  cases  of  pulmonary  tubercu- 
losis treated  since  its  opening,  43.39  per  cent  of  cases  were  arrested 
or  apparently  cured,  and  in  addition,  47.38  per  cent  were  improved."' 

From  what  has  been  said,  it  is,  therefore,  not  surprising  that 
claims  are  made  that  there  is  a  noticeable  difference  in  the  character 
of  fogs  on  the  New  England  Coast.3  Dr.  Bowditch  has  described 
the  fogs  on  the  Maine  Coast  as  sometimes  "  dry  fogs."  "  The  light 
vapory  mist  which  drives  in  frequently  from  the  sea  has  no  definite 
sense  of  moisture  as  it  strikes  the  face,  and  in  the  midst  of  it  the  air 
frequently  feels  dry.  In  the  vicinity  of  Mount  Desert,  the  presence 
of  the  mountains  has,  doubtless,  an  effect  upon  the  quality  of 
the  atmosphere,  and  would  partly  account  for  what  is  often  spoken 
of — the  effect  of  sea  and  mountain  air  combined.  Its  peculiar  dry- 
ness, even  though  on  the  coast,  has  been  often  so  marked  that  I 
have  frequently  thought  that  certain  phthisical  patients,  who  need 
a  dry  bracing  atmosphere,  might  improve  there,  although  I  have 
never  quite  dared  to  recommend  it  for  such  cases." 

SEA  AIR  FOR   SURGICAL  TUBERCULOSIS 

Halsted,  of  Baltimore,  however,  has  recorded  a  favorable  result 
in  a  case  of  tuberculous  glands  of  the  neck,  treated  simply  by  an  out- 
door life  on  the  Maine  coast.  The  patient  was  a  young  lady  of 
seventeen,  whose  cervical  glands  were  actively  inflamed  and  softened, 
the  overlying  skin  having  rapidly  reddened  and  thinned  during  a 
treatment  of  six  hours  a  day  out  of  doors  at  a  seashore  further 
south.  No  operation  was  done,  but  she  was  sent  to  the  Maine 
coast  and  lived  out-of-doors  day  and  night  for  four  months.  At  the 
end  of  this  period  no  one  could  tell,  from  the  appearances,  which 
side  had  been  affected,  and  Halsted  remarked  that,  to  surgeons  whose 
daily  bread  not  long  ago  was  tuberculous  glands  of  the  neck,  such  a 


1  Journal  of  the  Outdoor  Life,  February,  1908,  p.  15. 

2  Eleventh   Annual   Report,   1907. 

8  Vincent  Y.  Bowditch,  Trans.  Amer.  Climat.  Ass.,  1897,  p.  25. 


60  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

resolution  foretells  a  revolution  in  treatment.1    That  revolution  is, 
fortunately,  to-day  un  fait  accompli. 

Some  of  the  European  sanatoria  of  the  best  grade  are  in  situations 
not  altogether  free  from  fogs  and  mists.  This  is  true  of  Falkenstein, 
elevation  1,378  feet  (420  m.),  whose  atmosphere  is  a  little  misty 
and  foggy. 


AIR    OF    INLAND    SEAS    AND    LAKES 

The  region  of  the  Great  Lakes  lying  between  the  United  States 
and  Canada  has  been  studiously  avoided  in  selecting  a  site  for  any 
of  the  large  sanatoria  for  tuberculosis.  It  is  a  matter  of  common 
observation  that  nasal,  pharyngeal,  and  bronchial  catarrhs  are  exceed- 
ingly common  in  adjacent  districts.  The  lake  winds  are  damp  and 
are  partly  frozen  during  several  months  in  the  year,  giving  to  the 
surrounding  country  a  harsh  climate. 

The  lower  lake  region  is  also  the  favorite  track  of  storms  or 
cyclonic  atmospheric  movements  which  sweep  the  lakes  and  the 
St.  Lawrence  valley  on  their  way  to  the  seaboard.  As  these  areas 
of  low  atmospheric  pressure  advance  they  are  attended  by  increas- 
ing cloudiness  in  front  and  are  usually  followed  by  colder  air  from 
the  Northwest,  the  fall  in  temperature  being  sufficient  at  times  to 
constitute  a  cold  wave.3 

The  winter  storms  on  the  Great  Lakes  are  quite  as  violent  as  any 
on  the  seacoast,  and  on  Lake  Superior  and  Lake  Huron  floating 
ice  may  be  seen  in  May  and  sometimes,  in  Lake  Superior,  as  late 
as  June.  Lakes  Michigan,  Erie  and  Ontario  are  more  southerly,  but 
their  shores  are  low  and  the  skies  are  notably  cloudy.  The  author 
has  experience  of  the  cold  fogs  of  Lake  Superior  in  July  and 
August,  and  was  impressed  with  their  penetrating  quality.  A  sum- 
mer spent  on  both  the  northern  and  southern  shores  of  Lake  Supe- 
rior was  wonderfully  exhilarating ;  the  air  has  a  purity  and  stimulus 
such  as  one  might  expect  from  millions  of  miles  of  forest  round- 
about. But  not  a  single  place  on  that  vast  shore  can  be  recommended 
as  a  residence  for  a  tuberculous  patient.  The  vicissitudes  of  the 
weather  are  such  that  the  approved  methods  of  cure  could  not  well 
be  carried  out. 


1  Trans.  Nat'l  Ass.  for  the  Study  and  Prevention  of  Tuberculosis,  1906. 

3  To  constitute  a  cold  wave,  so  called,  there  must  be  a  fall  of  twenty  degrees 
or  more  in  twenty-four  hours,  free  of  diurnal  range  and  extending  over  an 
area  of  at  least  50,000  square  miles,  the  temperature  somewhere  in  the  area 
going  as  low  as  36°  F. 


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NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  ''I 

In  the  location  of  the  state  sanatorium  for  tuberculous  patients 
in  Minnesota,  an  interior  and  northerly  location  was  wisely  chosen, 
150  miles  south  of  Lake  Superior,  at  Lake  Pokegama,  near  the  head- 
waters of  the  Mississippi. 

The  Wisconsin  State  Sanatorium  has  been  located  on  Lake  Neba- 
gamon,  thirty  miles  from  Lake  Superior. 

Such  small  lakes  as  Lake  Pokegama  in  Minnesota ;  the  Muskoka 
Lakes  in  Ontario,  where  the  Canadian  National  Sanitarium  Associa- 
tion has  established  two  sanatoria  for  consumptives  ;  and  the  Saranac 
Lakes  in  the  Adirondack  Mountains,  have  no  such  power  to  modify 
the  qualities  of  the  atmosphere.  Whatever  influences  are  attributa- 
ble to  these  smaller  bodies  of  water  are  small,  compared  with  that 
of  the  forest  and  mountains.  Undoubtedly  a  small  lake  is  a  desir- 
able feature  in  connection  with  a  sanatorium,  as  it  provides  sources 
of  amusement  throughout  the  year  and  adds  greatly  to  the  beauty  of 
the  landscape.  The  writer  spent  six  summers  at  Lake  Placid  in  the 
Adirondack  Mountains  at  an  elevation  of  1,860  feet.  This  is  some- 
what more  protected  than  the  Saranac  Lakes,  St.  Regis  Lake  or 
Long  Lake,  and,  in  his  opinion,  is  quite  as  well  suited  as  a  residence 
for  tuberculous  patients  as  any  other  locality  in  the  Adirondacks. 
The  State  of  New  York  has  built  its  large  State  Sanatorium  at 
Ray  Brook  only  four  miles  distant  from  Lake  Placid.  The  State  of 
Rhode  Island  has  chosen  Wallum  Lake  for  its  new  Sanatorium, 
views  of  which  are  here  given.1 

CHAPTER    IV.     INFLUENCE   OF   COMPRESSED   AND   RAREFIED 
AIR;    HIGH   AND   LOW   ATMOSPHERIC    PRES- 
SURE;  ALTITUDE 

No  phase  of  the  tuberculosis  question  has  been  so  vigorously 
debated  as  the  influence  of  altitude;  no  feature  of  the  subject  is  so 
far  from  satisfactory  solution.  The  battles  between  the  Highlanders 
and  the  Lowlanders  of  Scotland  seem  to  have  been  revived  in  the 
attempts  to  settle  this  question.  Instead  of  the  claymore  and  battle- 
axe,  we  have  an  array  of  statistics  in  serried  columns  marshalled  by 
the  leaders  of  the  opposing  forces.  This  history  of  the  conflict 
would  make  as  large  a  record  as  the  Medical  and  Surgical  History 
of  the  War  of  the  Rebellion.     And  the  end  is  not  yet  in  sight. 

After  trying  for  years  to  cure  consumption  by  means  of  an  "  equa- 
ble climate  "  obtained  at  home  by  housing  the  patient  behind  double 


1  The    large    German    Sanatorium    Grabosee    is    located   on   the    shores    of 
Lake  Grabow. 


62  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

windows,  or  by  sending  him  to  the  islands  of  the  sea,  such  as 
Madeira  and  the  West  Indies,  the  medical  profession  began  to  be  im- 
pressed with  the  good  results  reported  from  the  Rocky  Mountains 
and  the  plains  of  the  Western  states  and  territories. 

In  the  rush  to  the  California  gold  fields  in  1849  and  in  the  rapid 
emigration  from  Eastern  states  to  Colorado,  Utah,  California,  over- 
land in  the  "  prairie  schooner  "  and  on  horseback  during  subsequent 
years,  the  Western  country  became  known  for  wonderful  health- 
giving  qualities.  It  was  not  long  before  Colorado  became  widely 
heralded  as  a  health  resort  for  consumptives.  English  physicians 
sent  their  patients  to  Colorado  instead  of  sending  them  to  Australia, 
Algiers,  or  to  the  Riviera  and  the  results  obtained  were  remarkable. 
The  late  Dr.  S.  E.  Solly,  who  practiced  in  Colorado  for  thirty-three 
years,  was  sent  from  London  on  account  of  the  higher  altitude  and 
better  air  of  Colorado,  and  was  one  of  a  large  number  of  English 
residents  who  have  made  their  home  in  that  state  on  account  of 
pulmonary  tuberculosis. 

In  1876,  the  late  Dr.  Charles  Theodore  Williams,  of  London, 
published  his  report  to  the  International  Medical  Congress  and  in 
1894  issued  his  work  on  Aero-Therapeutics,  in  which  are  detailed 
the  histories  of  202  consumptives  who  were  sent  to  Colorado  at  an 
altitude  of  5,000  or  6,000  feet.  They  represented  a  residence  of  350 
years  at  this  elevation  and  the  results  were  exceedingly  satisfactory. 

Jourdanet,  a  French  physician  practicing  in  Mexico,  published  two 
works,  one  in  1861  and  one  in  1875,  which  undertook  to  explain  the 
influence  of  barometric  pressure  and,  incidentally,  why,  on  the  plain 
of  Anahuac,  6,000  feet  in  elevation,  there  is  an  entire  absence  of 
pulmonary  phthisis.1 

Jourdanet  aided  the  great  French  physiologist,  Paul  Bert,  in  estab- 
lishing costly  apparatus  for  investigating  the  physiological  action  of 
compressed  and  rarefied  air  and  Paul  Bert's  classic  work  is  an 
accepted  authority  on  this  subject.  Later  studies  by  Mosso  and 
Marcet 2  should  be  noted,  but  it  is  impossible  here  to  give  more  than 
passing  notice.  They  show  that  a  diminution  of  the  barometric 
pressure  increases  the  respiration  rate  and  the  volume  of  air  respired, 
but  if  allowances  are  made  for  the  increase  of  volume  of  the  air 
at  the  lower  pressure,  the  actual  volume  respired  is  less.  Conversely, 


1 D.  Jourdanet :  Influence  de  la  Pression  de  l'Air,  Paris,  1875.  Herrera 
and    Lope :     I_a   Vie    Sur    Hauts    Plateaux,    Hodgkins    Prize    Memoir,    1898. 

2  An  American  Text-Book  of  Physiology,  Phila.,  1901,  Vol.  1,  p.  434. 
Angello'  Mosso :  Man  in  the  High  Alps  (Der  Mensch  auf  den  Hochalpen, 
Leipsig,   1899),  Translation  by   E.  L.   Kiesow,   1898. 


NO.    I  AIR    AND    TUBERCULOSIS HINSDALE  63 

an  increase  of  pressure  lowers  the  rate  and  the  volume  of  air 
respired.  The  effects  of  the  respiration  of  rarefied  air  and  com- 
pressed air  on  the  circulation  and  on  the  composition  of  the  blood 
are  very  marked  and  are  of  a  complex  character  owing  to  the  addi- 
tional influences  of  the  abnormal  pressure  on  the  peripheral  circula- 
tion. Not  only  is  the  circulation  affected  but,  in  the  case  of  residence 
at  high  altitudes,  the  proportion  of  red  blood  corpuscles  and  of  hemo- 
globin is  notably  increased.  This  increase  in  the  red  blood  count 
at  the  higher  altitudes,  while  not  so  great  or  so  permanent  as  was 
at  first  supposed,  is  an  established  clinical  fact  and  adds  undoubted 
strength  to  the  claim  that  altitude  per  se  is  a  characteristic  of  the 
favorable  climate  for  tuberculous  patients. 

DIMINISHED   ATMOSPHERIC    PRESSURE 

The  influence  of  diminished  atmospheric  pressure  on  the  blood  has 
been  studied  by  Paul  Bert  in  1882,1  Zuntz,2  P.  Regnard,3  Viault,4 
Egger,5  Woolff/  Koeppe,7  Solly,8  by  W.  A.  Campbell  and  Gardiner 
and  Hoagland,9  by  L.  S.  Peters  10  and  by  F.  Laquer.11    One  of  the 


1  Paul  Bert,  loc.  cit.,  studied  the  blood  of  animals  at  La  Paz,  in  Mexico, 
at  an  altitude  of  12,140  feet  (3,700  meters)  and  found  that  they  had  an 
oxygen-carrying  capacity  far  in  excess  of  that  exhibited  by  the  animals  on 
the   lower   plains. 

2  Zuntz :  Experiments  on  the  Pic  du  Midi,  Elevation  9,000  feet.  He  empha- 
sized the  possibility  of  an  altered  distribution  of  corpuscles. 

3  Regnard,  P. :    La  Cure  d'Altitude,  2eime  Ed.  Paris,  1898. 

4  Viault :  Experiments  at  Merococha,  Peru,  elevation  14,275  feet.  1890.  He 
noted  that  his  blood  contained  7  to  8  million  red  corpuscles  per  cubic  milli- 
meter. 

6  Egger :  The  Blood  Changes  in  High  Mountains.  Verhandlungen  d.  xii, 
Congr.  Inner.  Med.,  1893. 

8  Woolff :    Verhandlungen  d.  xii.  Congr.    Inner  Med.  1893,  pp.  262-276. 

7  Koeppe,  xii.  Congress  fur  Inner.  Med.,  1893 ;  Arch.  Anat.  Physiol.,  1895, 
pp.  154-184. 

8  S.  E.  Solly :  Blood  Changes  Induced  by  Altitude.  Trans.  American 
Climatological  Association,  1899,  p.  144;  also  1900,  p.  204. 

S.  E.  Solly,  Therapeutic  Gazette,  February,  1896. 

9  Campbell  and  Hoagland :  Trans.  American  Climatological  Association, 
1901,  p.   107. 

10  For  the  effect  of  altitude,  6,000  feet,  on  blood  pressure  in  tuberculous 
patients,  see  article  by  L.  S.  Peters,  Silver  City,  New  Mexico,  in  Archives 
of  Internal  Medicine,  August,  1908  and  October,  1913.  The  latter  report 
covers  600  cases  and  shows  that  altitude  tends  to  raise  blood  pressure  rather 
than  lower  it  both  in  consumptives  and  in  normal  persons  living  at  high 
altitudes. 

11  F.  Laquer :  Hohenclima  und  Blutneubildung,  Deutsches  Archiv  fur  klin. 
Med.    Leipzig,  1913,  ex,  Nos.  3  and  4,  p.  189. 


64  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

most  thorough  original  studies  is  by  Drs.  Ossian,  Schaumann  and 
Emil  Rosenquist,  of  Helsingfors,  Finland.1  Turban,  also,  has  made 
a  study  of  this  subject.2 

Much  of  the  earlier  work  has  been  proved  incorrect  as  instru- 
mental and  laboratory  technic  has  been  improved.  Hematologic 
work  has  made  rapid  strides  and  several  important  correcting  factors 
have  been  introduced.  Attention  has  been  called  to  the  more  rapid 
evaporation  of  blood  samples  at  high  altitudes  where  the  climate  is 
always  dry  and  errors  from  this  source  are  considerable. 

Not  only  that,  but  the  human  organism  itself  loses  water  more 
readily  than  at  lower  levels  and  so  do  animals  used  for  experimental 
purposes.  How  much  value  should  be  given  to  these  corrections  we 
do  not  know,  but  there  is  evidently  a  revision  downwards  noticeable 
in  nearly  all  the  later  studies  of  the  blood  count  at  high  altitudes. 
Prof.  Biirker,  of  Tubingen,  and  his  colleagues  show  at  best  only  a 
comparatively  small  increase  amounting  to  only  four  to  eleven  and  a 
half  per  cent  at  an  altitude  of  six  thousand  feet.3 

These  observers  made  comparative  observations  at  Tubingen 
(altitude  1,030  feet  or  314  meters),  and  at  the  Sanatorium  Schatzalp 
(altitude  6,150  feet  or  1,874  meters,  about  300  meters  above  Davos). 

Biirker's  findings,  which  appear  to  result  from  an  exceptionally  careful 
personal  investigation  with  every  precaution  to  avoid  experimental  error,  show 
that  altitude  does  exert  an  unquestionable  influence  on  the  blood  in  the  direc- 
tion of  an  increase  in  both  the  number  of  erythrocytes  and  the  content  of 
hemoglobin.  The  increase  is  an  absolute  one,  not  merely  relative.  The  red 
cells  increased  from  4  to  11.5  per  cent,  the  hemoglobin  from  7  to  10  per 
cent.  These  figures,  it  will  be  noted,  are  smaller  than  those  usually  given 
for  the  effect  of  moderate  altitudes,  yet  they  represent  substantial  and  unde- 
niable gains  quite  in  harmony  with  other  previous  observations. 

The  responses  of  the  different  persons  in  Biirker's  Alpine  expedition  varied 
in  degree;  but  the  qualitative  examination  of  the  blood  established  the  fact 
that  no  hemoglobin  derivative  other  than  oxyhemoglobin  was  concerned  in 


1  Ossian,  Schaumann  and  Rosenquist :  Ueber  die  Natur  d.  Blutverander- 
ungen  in  Hohen  Klima,  Zeitschr.  f.  klin.  Med.,  1898,  Band  xxxv,  Heft  1-4, 
pp.  126-170  and  315-349. 

2  Turban,  Munch.  Med.  Wochenschr.,  1899,  p.  792. 

3  See  Editorial  Altitude  and  the  Blood  Corpuscles,  Journ.  Amer.  Med.  Ass., 
February  3,  1912,  p.  344;  September  21,  1912  and  November  1,   1913. 

Biirker,  K. ;  Jooss,  E. ;  Moll,  E.,  and  Neumann,  E. :  Die  physiologischen 
Wirkungen  des  Hohenklimas :  II.  Die  Wirkung  auf  das  Blut,  gepriift  durch 
tagliche  Erythrozytenzahlungen  und  tagliche  qualitative  und  quantitative 
Hamoglobinbestimmlungen  im  Blute  von  vier  Versuchspersonen  wahrend 
eines  Monats,  Ztschr.  f.  Biol.,  1913,  Vol.  61,  379. 


NO.    I  AIR   AXD    TUBERCULOSIS — HINSDALE  65 

the  increment  at  altitudes.  In  agreement  with  most  observers  the  adjustment 
of  the  blood  to  the  new  atmospheric  conditions  in  ascending  to  higher  levels 
occurs  promptly;  there  is  a  rapid  increase  in  the  factors  involved  at  the 
start  followed  by  a  more  gradual  continuation  of  the  effect;  but  on  returning 
toward  the  sea-level  the  blood  does  not  resume  its  "  low  altitude "  composi- 
tion so  promptly.  There  may  be  a  prolonged  delay  in  the  adjustment 
and  return  to  normal  figures.1 

Cohnheim2  regards  evaporation  as  the  cause  of  the  concentration 
of  blood  under  these  conditions  and  that  this  is  not  due  to  a  lack  of 
oxygen.  These  studies  in  hematology  have  an  important  bearing  on 
the  course  of  tuberculosis  at  high  altitudes,  and  constitute  a  very 
live  question  at  the  present  day. 

Professor  Cohnheim  and  Dr.  Weber 3  have  recently  reported  the  results 
of  examination  of  the  blood  of  twenty-three  persons  who  have  been  engaged 
for  long  periods  in  the  operations  of  the  railway  ascending  the  Jungfrau  peak 
in  the  Alps.  Most  of  them  spent  considerable  portions  of  their  time  at  alti- 
tudes from  2,300  meters  (7,546  feet,  Eigergletscher  Station)  upward  to 
3,450  meters  (11,319  feet,  Jungfraujoch  Station).  The  importance  of  these 
observations  lies  in  the  fact  that  they  furnish  data  regarding  persons  who 
have  had  prolonged  experience  in  the  higher  altitudes  so  that  the  incidents 
of  temporary  residence  and  change  of  scene  may  be  regarded  as  equalized  or 
eliminated.  They  supplement  the  earlier  records  from  the  South  American 
plateaus  by  results  obtained  with  approved  and  up-to-date  procedures.  The 
new  statistics  agree  in  exhibiting  values  both  for  red  blood-corpuscles  and 
hemoglobin  distinctly  higher  than  the  "normals"  of  sea  level.  Cohnheim 
maintains  that  the  high  figures  thus  obtained  on  a  large  scale  from  subjects 
accustomed  to  live  at  high  atmospheric  levels  leave  no  alternative  except  to 
assume  a  new  formation  of  corpuscles  under  such  conditions.  Where  contrary 
conclusions  have  been  reached — and  there  are  many  such — it  is  not  unlikely 
that  the  period  of  residence  was  too  brief  to  permit  the  stimulating  effects 
of  altitude  to  manifest  themselves  in  any  conspicuous  way. 

The  renewed  assumption  of  an  increased  functioning  of  the  hemopoietic 
organs  at  high  altitudes  has  further  been  supported  by  observations  conducted 
on  Monte  Rosa  in  the  Alps  relating  to  the  regeneration  of  blood  after  severe 
anemias.  In  the  international  laboratory  built  on  the  Col  d'Olen  at  an  altitude 
of  2,900  meters  (9,515  feet)  and  dedicated  to  the  memory  of  Angelo  Mosso, 
Laquer  3  has  found  that  dogs  deprived  by  hemorrhage  of  half  their  blood- 
supply  regenerate  it  in  about  sixteen  days.  Under  precisely  comparable 
experimental  conditions  twenty-seven  days  are  required  at  lower  levels  for  the 
restoration  of  the  same  blood  loss.  Laquer  believes  that  the  lower  partial 
pressure  of  the  oxygen  is  the  effective  stimulating  factor  in  this  more  pro- 


1  Editorial  in  Journ.  Amer.  Med.  Ass.,  Nov.  1,  1913,  q.  v. 

2  For  a  recent  review  of  this  subject  see  Cohnheim,  O. :  Physiologie  des 
Alpinismus,  II.  Ergebn.  d.  Physiol.,  1912,  xii,  628;  also  Anglo-American 
Expedition  to  Pike's  Peak,  Journal  Amer.  Med.  Ass.,  Aug.  10,  1912,  p.  449. 

3 Cohnheim,  O.,  and  Weber:  Die  Blutbildung  im  Hochgebirge,  Deutsch. 
Arch.   f.  klin.  Med.,   1913,  ex,  225. 


66 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 


nounced  regeneration  so  strikingly  shown  at  great  heights.  How  long  this 
latest  explanation  will  withstand  the  attacks  of  the  increasing  number  of 
Alpine  physiologists  remains  to  be  seen.1 

The  latest  observations  show  that  arterial  blood  contains  con- 
siderably more  oxygen  at  high  altitudes  than  at  sea  level.  The 
pulmonary  alveoli  have  a  special  power  of  extracting  or  secreting 
oxygen  and  this  power  is  increased  in  high  altitudes,  this  increase 
not  disappearing  until  a  considerable  time  after  descent  to  sea  level. 

W.  R.  Huggard,  of  London,  an  unbiassed  and  judicial  observer, 
says  :  "  The  diminished  frequency  of  tuberculosis  with  altitude  may, 
I  think,  be  taken  as  established."  2  Hirsch 3  held  the  same  opinion  and 
based  his  statement  on  statistics  from  various  places. 

Thirteen  years  ago,  Dr.  Solly  endeavored  to  show  this  statistically 
and  arranged  three  tables  which  we  append. 


TABLE  I 
Comparative  Results  in  Sanatoria  in  High  and  Low  Climates 
combined  first  and  second-stage  cases  only 
(Taken  from  Dr.  Walters,  pp.  52  and  53) 


1876-1886 

Altitude 

Number  of 
Cases 

Number 
Benefited 

Per  Cent 

LOWLAND   CLIMATES 

Reiboldsgriin  (Driver) 

1,840  ft. 

1,375  ft. 
2,300  ft. 

3,6l5 
1,022 
2,000 

1,294 

746 

1,400 

3,440 

34 
269 
212 

36 

73  ]  71 
70S' 

Total 

6,637 

37 
302 

259 
598 

Average.  51 

HIGHLAND   CLIMATES 

Leysin  (Bernier) 

4,150  ft. 
5,115  ft. 

6,000  ft. 

92 

89 
82 

Davos  (Turban) 

Arosa  (Jacobi) 

Total :. 

515 

Average,  86 

The  total  average  of  benefited  in  low  climates  was  71  per  cent1 

"    high      "  "    86 

1  Without  Goerbersdorf. 

The  Goerbersdorf  reports  up  to  1884  are  so  much  lower  in  the  percent  of 
benefited  to  the  others — owing,  perhaps,  to  some  different  method  of  estimating 
results,  or,  perhaps,  to  their  being  taken  so  many  years  ago,  when  the  material 
was  worse  and  the  treatment  perhaps  not  as  efficient — that  probably  it  would 
bring  out  the  truth  better  to  omit  them. 


1  Editorial  in  Journ.  Amer.  Med.  Ass.,  July  26,  1913. 

2W.  R.  Huggard:  A  Handbook  of  Climatic  Treatment,  London,  1906,  p. 
124. 

3  Hirsch :  Geographical  and  Historical  Pathology,  New  Sydenham  Society 
Translation,  1886,  Vol.  3,  p.  440. 


NO.    I 


AIR   AND   TUBERCULOSIS — HINSDALE 


67 


TABLE  II 
Comparative  Results  in  Open  Resorts  in  Low  and  High  Climates 

all    stages 
(Taken  from  Handbook  of  Climatology,  Solly,  pp.  132  and  133) 


lowland  climates 

Desert  Climates 

Island  Climates 

Coast  Climates 

Inland  Climates 


Total 3, 1 

HIGHLAND    CLIMATES 

Alps   (Davos) 

Colorado 


Total 


Number  of 
Cases 

Number 
Benefited 

154 

568 

2,328 

136 

100 

295 

1,369 

77 

3,186 

1,841 

2,027 

i,55i 

571 

420 

2,598 

1,971 

Per  Cent 


65 

52 
59 
57 

Average,  58 


17 
73 

Average,  76 


The  total  average  of  benefited  in  lowland  climates  was  57  per  cent 
"        "    highland      "  "     76  per  cent 

The  first  table,  Table  I,  deals  with  the  comparative  results  in  sana- 
toria in  high  and  low  climates,  first  and  second  stage  cases  combined 
being  alone  taken,  and  the  different  variety  of  forms  of  improvement 
being  grouped  under  the  head  of  benefited.  Of  the  lowland  sanatoria 
the  lowest  elevation  above  sea-level  was  1,840  feet,  and  the  highest 
3,300  feet.  Of  the  highland  climates  the  lowest  elevation  was  4,150 
feet,  and  the  highest,  6,000  feet.  The  total  average  percentage  of 
benefited  in  low  climates  was  71,  and  in  high  climates  86. 

Table  II  gives  comparative  results  in  open  resorts  in  low  and 
high  climates.  The  total  average  of  benefited  in  lowland  climates 
was  57  per  cent,  in  highland  climates  76  per  cent. 

TABLE  III 

Comparative  Results  in  High  and  Low  Climates  in  Open 

and  Closed  Resorts 


Sanatoriums 


LOWLAND  CLIMATES 

Hygeia   (A.  Klebs) 

Goerbersdorf  (Brehmer).. 

Adirondacks  (Trudeau)... 

Average 

HIGHLAND  CLIMATES 

Davos  (Turban) 

Arosa   (Jacobi) 

Average 


Per  Cent 

Benefited 

Open  Resorts 

69 
76 

71 
74 

Average  percent  of  benefited, 

58 

84 

Average  percent  of  benefited, 

16 

68  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

Table  III  shows  the  comparative  results  in  high  and  low  climates 
in  open  and  closed  resorts.  The  cases,  however,  could  not  be  ob- 
tained in  first  and  second  stage  cases  alone,  but  only  of  all  stages 
combined.  In  lowland  climates  the  closed  sanatoria  show  74  per  cent 
benefited,  and  the  open  resorts  58  per  cent  benefited.  In  highland 
climates  the  closed  sanatoria  show  84  per  cent  benefited  and  the  open 
resorts  76  per  cent,  exhibiting  the  relative  superiority  of  sanatorium 
over  open  resort  treatment  in  the  two  classes  of  climates,  respec- 
tively. Doubtless  the  sanatorium  cases  were  on  the  whole  in  better 
condition  upon  first  coming  under  treatment  than  those  in  the  open 
resorts  and,  therefore,  the  superiority  of  sanatorium  treatment  over 
open  methods  is  probably  not  as  great  as  it  appears  here ;  but,  never- 
theless, even  if  the  material  were  exactly  the  same,  the  sanatoria 
would  show  a  greater  percentage  of  benefited  over  the  open  resorts. 

Table  III  also  proves  that  climate  exercises  a  beneficial  influence 
over  patients  in  closed  sanatoriums  as  well  as  in  open  resorts.  In 
all  stages  combined  the  percentage  of  benefited  in  sanatoria  in 
low  climates  was  74  per  cent,  while  in  high  climates  it  was  84  per 
cent. 

In  the  first  and  second  stage  cases  combined  (see  in  Table  I), 
the  difference  in  favor  of  mountain  sanatoria  is  still  greater — low- 
land sanatoria  71  per  cent ;  highland  sanatoria  86  per  cent.1 

The  following  is  the  classification  of  the  National  Association  for 
the  Study  and  Prevention  of  Tuberculosis  adopted  in  May,  1913. 
The  data  given  in  the  table  on  page  69  are  given  in  terms  generally 
used  up  to  that  time. 

CLASSIFICATION   OF   SUBSEQUENT   OBSERVATIONS 

Apparently  Cured :  All  constitutional  symptoms  and  expectoration  with  bacilli 
absent  for  a  period  of  two  years  under  ordinary  conditions  of  life. 

Arrested:  All  constitutional  symptoms  and  expectoration  with  bacilli  absent 
for  a  period  of  six  months ;  the  physical  signs  to  be  those  of  a  healed 
lesion. 

Apparently  Arrested :  All  constitutional  symptoms  and  expectoration  with 
bacilli  absent  for  a  period  of  three  months ;  the  physical  signs  to  be 
those   of   a   healed   lesion. 

Quiescent :  Absence  of  all  constitutional  symptoms ;  expectoration  and  bacilli 
may  or  may  not  be  present ;  physical  signs  stationary  or  retrogressive ;  the 
foregoing  conditions  to  have  existed  for  at  least  two  months. 

Improved :  Constitutional  symptoms  lessened  or  entirely  absent ;  physical 
signs  improved  or  unchanged;  cough  and  expectoration  with  bacilli  usu- 
ally present. 

Unimproved :    All  essential  symptoms  and  signs  unabated  or  increased. 

Died. 


1  Dr.  S.  E.  Solly,  in  the  Philadelphia  Medical  Journal,  December  1,  1900. 


NO.    I 


AIR   AND    TUBERCULOSIS — HINSDALE 


69 


It  is  practically  impossible  to  draw  accurate  conclusions  from  data 
furnished  by  different  institutions,  under  such  wide  variations  as  to 
the  character  of  the  patients  and  varying  standards  as  to  what 
constitutes  an  apparent  cure  or  arrested  disease.  A  glance  at  the 
chart  or  table  shows  that  s:ood  results  are  obtained  at  all  eleva- 


Sanatoria 

a 
0 

> 
u 

S 

a   3 

< 

•0 

<u 

<u  in 

(A   O 

5 

•0 
0 

0 
u 

O, 

£ 

1— 1 

0 
> 

0 

u 

a, 

a 

'5 
P 

■a 
u 

5 

u 
a 

Stage 

Sharon,  Mass. 

feet 
250 

per 
cent 
56 

per 
cent 
18 

per 

cent 
33 

per  \   per 

cent    cent 

9        

1891-1911 

All 

Barlow,  Los  Angeles,  Cal. 

300 

3 

3-S 
16 
3i-i4 

4 
6 
16 

14.7 

40 
39-5 
42.8 
32.8 

35          13 
27.5      22 
9            i-7 
9-8       6.5 

1907 
1903-7 
1912 
1913 

All 

l_Chiefly  ad- 
| vanced 

Wallum  Lake,  R.  I.    (State) 

650 

8-5 
6.7 

32-9 

27.4 

33-6 
38.3 

23-7        1 
24.9       2.5 

Previous 
to  1912 
1912 

I  All 

Muskoka,  Canada 

700 

5-54 

20.8 

45-41 

24.56     3.67 

1902-12 

All 

Pottenger,  Monrovia,  Cal. 
(Private) 

1000 

68 

25 

8 

21 
50 
33 

11 
17 
36 

1909 
to 
1912 

4 

8 

4 
15 

<  Second 
LThird 

Otisville,  N.  Y.  (State) 

1200 

12 

47-3 

27.7 

10.5 

1-3 

1913 

All 

Rutland,  Mass.  (State) 

1165 

26.1 

35-6 

29-5 

9 

1906 

Early 

New  Jersey  State  (Glen 
Gardner) 

900 

12 

29 

42 

16 

1 

1912 

All 

White  Haven,  Pa.  (Free 
Hospital) 

1250 

17. 1 

59-9 

13-7 

3-3 

1901-13 

All 

Adirondack  Cott.  Sanitarium, 
Saranac  Lake,  N.  Y. 

1750 

4S.3 
8.8 

36.3 
48.2 

15-4  

43       !  4-2 

1885-1911 

Incipient 

far  advanced' 

Ray  Brook,  Adirondacks,  N.  Y. 
(State) 

163S 

34-4 

31-6 

17-3 

14       j     .9 

1912 

All 

New   Mexico  Cottage  Sanita- 
rium, Silver  City  (600  cases, 
Private) 

6000 

83 
SO 
13 

17 
33 
30 

1904-13 

8 
25 

6           2 
26       ;     4 

19% 

vanced,  19% 

62% 

U.   S.    Public  Health  Service 
Sanatorium,   Fort   Stanton, 
N.  M.    (For  Sailors) 

6231 

11. 7 

15 

29.1 

9-5 

34-5 

1899-1912 

All 

U.    S.   Army    Hospital,    Fort 
Bayard,  N.  M. 

6400 

2.02 
4.78 

2.87 
11 .40 

69.25 
52.38 

19-59 
23.80 

6.25 
7.64 

1911 
1912 

All 
All 

tions.  The  best  results  are  claimed  in  incipient  cases  by  the  Potten- 
ger (Private)  Sanatorium,  Monrovia,  California,  1,000  feet,  and 
New  Mexico  Cottage  Sanatorium,  Silver  City,  New  Mexico,  6,000 
feet. 

INSOLATION.     DIATHERMANCY  OF  AIR.     ALPINE  RESORTS 

Associated  with  diminished  atmospheric  pressure  are  other  impor- 
tant and  inseparable  atmospheric  qualities  which  contribute  largely 


JO  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

to  the  resultant  influence  on  man's  welfare  in  the  higher  altitudes. 
These  other  qualities  have  a  special  influence  on  pulmonary  tubercu- 
losis and  should  be  recognized  in  estimating  the  effect  on  patients 
of  this  class. 

We  have,  first,  greater  insolation.  The  part  played  by  the  earth's 
atmosphere  in  arresting  the  sun's  rays,  is  very  important  and  second 
only  to  the  influence  of  the  atmosphere  of  the  sun  itself  in  arresting 
the  radiation  of  light  and  heat  from  the  sun.  Slight  changes  in  the 
sun's  atmosphere  would  speedily  alter  the  terrestrial  climate.  On 
the  earth's  surface  at  sea  level  the  energy  of  light  of  the  sun  and  that 
of  the  heat  rays  are  considerably  less  than  at  the  higher  altitudes  and 
recent  measurements  are  of  great  interest  and  practical  value. 

Dr.  Julius  Hann,  the  great  meteorologist  of  Vienna,  has  noted  that 
on  the  lower  plains  thirty  to  forty  per  cent  of  the  total  amount  of 
the  sun's  heat  was  absorbed  by  the  earth's  atmosphere,  whereas  at 
the  summit  of  Mt.  Blanc,  at  15,730  feet  (4,810  meters)  elevation, 
nearly  one-half  of  the  absorbing  mass  of  the  air  is  lost  and  the 
amount  of  the  sun's  heat  absorbed  was  not  more  than  6  per  cent. 
One  can  readily  understand  that  when  the  resistance  is  removed 
the  light  rays  are  more  effective  than  at  sea  level.  The  late  Prof. 
S.  P.  Langley  showed  by  delicate  measurements  at  this  height  that 
the  blue  end  of  the  spectrum  grows  to  many  times  its  intensity  at  sea 
level.1  This  marked  diathermancy  of  the  atmosphere  goes  hand  in 
hand  with  altitude.  The  increased  facility  with  which  the  solar  rays 
are  transmitted  through  an  attenuated  air  accounts  for  the  tan  and 
sunburn  so  readily  acquired  on  mountain  tops  and  this  quality  is,  in 
the  author's  opinion,  of  value  in  the  prevention  and  treatment  of 
tuberculosis. 

Owing  to  the  increased  diathermancy  of  the  atmosphere  at  ele- 
vated stations  there  is  a  remarkable  difference  between  the  atmos- 
pheric temperature  in  the  sun  and  in  the  shade.  At  the  higher  Alpine 
resorts  for  tuberculous  patients,  such  as  Davos  (5,200  feet),  St. 
Moritz  (6,000  feet),  Arosa  (6>,ioo  feet),  and  Leysin  (4,757  feet), 
the  excessive  heat  in  the  sun  compared  with  shade  temperatures  in 
winter  favors  the  outdoor  life  during  the  "  invalid's  day."  It  also, 
incidentally,  impresses  all  newly  arrived  visitors  as  a  marvellous  cli- 
matic feature.  At  St.  Moritz,  now  a  fashionable  winter  resort,  ladies 
find  parasols  almost  a  necessity  while  friends  are  skating,  and  those 


1 S.  P.  Langley :  Researches  on  Solar  Heat  and  Its  Absorption  by  the 
Earth's  Atmosphere.  Papers  of  the  U.  S.  Weather  Bureau,  No.  15,  Wash- 
ington, 1884,  p.  242. 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  7 1 

who  indulge  in  this  Alpine  pastime  revel  in  summer  clothing.  Al- 
though the  climate  is  a  cold  one  it  is  characterized  by  great  diurnal 
ranges  of  temperature,  freedom  from  dust,  winds  and  fogs,  and  emi- 
nently suitable  for  the  climatic  cure. 

As  the  snow  lies  on  the  ground  at  these  resorts  for  from  three  to 
five  months,  sleighing,  skating,  skiing  and  tobogganing  are  popular 
and  some  of  these  sports  are  allowable  in  suitable  cases  of  tuberculo- 
sis. In  March  or  April  the  snow  melts  and  the  roads  become  slushy 
and  muddy,  so  that  the  air  becomes  very  damp,  and  patients  are 
accustomed  to  make  temporary  visits  to  lower  stations,  such  as 
Wiesen  (4,760  feet),  Seewis  (2,985  feet),  Thusis  (2,448  feet),  Gais 
in  Appenzell  (2,820  feet),  or  Ragaz  (1,709  feet),  returning  later  to 
the  higher  stations.1 

SURGICAL    TUBERCULOSIS    TREATMENT    IN    SWITZERLAND 

No  chapter  on  high  altitude  treatment  would  be  complete  at  the 
present  time  without  noting  the  brilliant  success  of  Dr.  A.  Rollier 
in  the  treatment  of  surgical  tuberculosis  at  Leysin,  in  the  Vaudois 
Alps,  Switzerland.  This  station  has  an  altitude  of  about  4,500  feet 
above  sea  level.  The  hospital  buildings  face  the  south  and  are  pro- 
tected by  mountain  ranges  from  the  cold  winds  of  the  north  and 
west.2  Rollier  states  that  even  in  midwinter,  with  snow  on  the 
ground,  the  temperature  on  the  sunny  balconies  is  often  as  high 
as  950  to  1200  F.  Owing  to  the  purity  of  the  atmosphere  and 
the  absence  of  moisture  there  is  little  loss  of  the  himinous  and 
caloric  radiation  of  the  sun.  Rollier  established  his  first  hospital  for 
the  treatment  of  tuberculosis  of  the  bones  and  joints  in  1903,  but  it 
is  only  during  the  last  two  or  three  years  that  his  method  has 
attracted  so  much  attention,  though  Bernard,  of  Samaden,  had  prac- 
ticed it  in  the  pure  mountain  air  of  Graubunden  in  the  Engadine; 
and  probably  this  influenced  Rollier  to  select  an  elevated  site  for  his 
hospitals.  These  are  three  in  number  and  are  located  at  1,250,  1,350 
and  1,500  meters,  or  3,800,  4,100  and  4,500  feet.    The  exposure  of 


1  See  Walter  B.  Piatt,  M.  D. :  The  Climate  of  St.  Moritz,  Upper  Engadine, 
Switzerland    (Trans.   Amer.   Climat.   Ass.,  Vol.   4,  p.    137). 

Arnold  C.  Klebs :  St.  Moritz,  Engadine  (Trans.  Amer.  Climat.  Ass.,  1906, 
Vol.  22,  p.  15). 

a  See  description  by  John  Winters  Brannan,  ,M.  D.,  Medical  Record,  June  7, 
1913.  Also  Rollier,  Paris  Medical,  January  7,  191 1,  and  February,  1913. 
The  author  is  indebted  to  Dr.  Brannan  for  his  data  and  to  Dr.  Rollier  for  the 
illustrations  and  descriptions  of  his  method. 


"]2  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

the  patient  to  the  sun  is  the  essential  feature  and  after  three  to  ten 
days  of  acclimatization  indoors  he  begins  with  five  minute  exposures 
of  the  feet,  five  times  a  day.  This  is  steadily  increased  as  pigmenta- 
tion appears  until  finally  the  entire  surface  of  the  body  is  exposed 
from  sunrise  to  sunset.  The  head  is,  however,  protected  with  white 
caps  and  shaded  glasses.  With  the  development  of  the  pigmentation 
the  cure  progresses  until  recovery  is  complete.  Dr.  Rollier  has  sent 
us  photographs  of  a  boy  who  had  32  foci  of  tuberculosis,  even  the 
lungs  being  involved.  This  boy  was  considered  cured  after  fifteen 
months  of  treatment.    See  plate  26. 

In  another  case  there  were  multiple  lesions,  including  a  badly  dis- 
organized and  anchylosed  elbow  with  seven  sinuses  and  a  history 
of  three  resections  of  the  joint  and  forearm.  This  boy  also  made 
a  good  recovery  with  complete  return  of  function,  full  flexion  and 
full  extension.  See  plate  27.  Dr.  Brannan  adds  that  he  has  seen 
many  such  cures  at  "  See  Breeze  "  and  has  kindly  furnished  photo- 
graphs of  some  of  these  patients.    See  plate  16. 

According  to  Rollier  the  pigmentation  is  the  important  element 
in  the  cure,  inasmuch  as  it  affords  to  the  skin  a  remarkable  resist- 
ance, favors  the  cicatrization  of  wounds  and  confers  a  local  immunity 
to  microbic  infections.  On  days  when  there  is  no  sunshine  recourse  is 
had  to  radiotherapy  for  the  adults  and  the  Bier  treatment  (local 
lowering  of  atmospheric  pressure)  for  the  children ;  at  all  times, 
whether  the  sun  shines  or  not,  the  skin  has  its  bath  of  air  and  light. 

Two  hundred  beds  in  Rollier's  sanatoria  are  reserved  for  children. 

Dr.  Rollier  presented  to  the  XVII  International  Medical  Congress 
at  London  in  1913,  a  resume  of  his  method  of  heliotherapy  and 
refers  to  eighteen  separate  communications  to  medical  literature,  in 
which  he  and  his  associates  have  described  the  method.  Among  other 
things  we  notice  that  he  reports  the  number  of  adults  having  external 
tuberculosis  treated  by  him  as  greater  than  that  of  children,  522  to 
477.  The  prognosis  for  the  former  is  as  favorable  as  for  the  latter 
and  the  duration  of  treatment  is  never  much  longer.  In  Rollier's 
paper,  referred  to,  all  his  cases  for  the  past  eleven  years  are  tabu- 
lated and  out  of  1,129  patients,  951  are  reported  cured.  Of  the  total 
number  only  three  underwent  the  operation  of  resection.  These 
were  cases  of  gonorrheal  arthritis ;  one  was  adult  of  over  fifty  years. 
Two  cases  of  tuberculosis  of  the  foot  were  treated  by  amputation ; 
both  were  adults  of  over  sixty  years. 

Rollier  uses  fixation  by  means  of  plaster,  especially  in  Pott's  Dis- 
ease, but  in  all  cases  insists  strenuously  that  the  tuberculous  joint 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    27 


m 

K 

■    1 

^ 

K^*^. 

#^P 

^Jllt* 

f£ 

■  W-Jx 

Wr 

^H  "     <     <* 

FOUR  ILLUSTRATIONS  OF  THE  SAME  CHILD.  HE  WAS  ADMITTED  TO  DR.  ROLLIER'S  SANATORIUM, 
LEYSIN,  AT  THE  AGE  OF  FIVE,  WITH  NUMEROUS  TUBERCULOUS  FOCI  IN  THE  BONE  AND  PERIOSTEUM 
AND  ABOUT  THE  RIGHT  EYE.  THERE  WAS  TUBERCULOSIS  OF  THE  ELBOW  AND  RIGHT  FOREARM. 
THREE  PREVIOUS  OPERATIONS.  SEVEN  FISTULOUS  OPENINGS  IN  THE  ELBOW;  SEVEN  IN  THE  FACE. 
JOINTS  IMMOVABLE;  GENERAL  CONDITION  BAD.  THE  TWO  LOWER  VIEWS  SHOW  THAT  AT  THE  END 
OF  ONE  YEAR   THE  OPEN   SORE  HAD  HEALED.     CHILD  VIGOROUS. 


NO.    I  AIR    AND    TUBERCULOSIS       II  I   >>l>  \l.l-.  73 

or  other  site  of  the  disease  must  not  be  covered  over  by  any  unre- 
movable apparatus  so  as  to  interfere  with  the  full  exposure  to  the 
sunlight.  Rollier's  last  paper  goes  very  fully  into  the  technic  of 
heliotherapy  and  the  reader  is  referred  to  this  and  to  the  fully  illus- 
trated paper  in  "  Paris  Medical,"  February,  191 3,  in  which  there  are 
forty-five  remarkable  photographs  covering  the  most  interesting  fea- 
tures of  this  work.  It  is  at  present  attracting  great  attention  and 
American  physicians  can  find  in  the  recent  review  of  Rollier's  work 
by  Dr.  Henry  Dietrich,  of  Los  Angeles,  California,  an  excellent 
summary  of  its  theory  and  practice.1 

Rollier,"  in  his  address  before  the  Gesellschaft  deutschcr  Natur- 
forscher  and  Aerzte  in  Minister  in  1912,  says: 

It  is  in  surgical  tuberculosis  that  we  have  seen  the  best  results  from  helio- 
therapy, and  we  have  made  the  treatment  of  it  our  life  work.  As  a  result 
of  my  experience  in  the  use  of  the  light-cure  in  higher  altitudes,  based  on  an 
experience  of  nine  years,  I  maintain  to-day  that  the  cure  of  surgical  tubercu- 
losis in  all  its  forms,  in  all  stages,  as  well  as  at  every  age  of  life,  can  be 
accomplished. 

The  closed  surgical  tuberculosis  always  heals,  if  one  will  only  be  patient, 
and  above  all  if  one  understands  how  to  keep  it  closed.  To  transform  a 
closed  tuberculosis  into  an  open  one  means  to  increase  the  gravity  of  the  case 
a  hundredfold.     A  diminution  of  the  vitality  of  the  tissues  is  the  inevitable 

consequence To  regard  a  surgical  tuberculosis  as  a  local  disease  which 

can  be  cured  by  local  treatment  alone  is  a  ruinous  error.     On  the  contrary, 


1  Journ.   Amer.   Med.   Ass.,   December  20,   1913,   p.  2232. 

2  References :  Rollier  ( Verhandl.  d.  Gesellsch.  f.  Kinderheilk.  d.  84  Ver- 
sainral.  d.  Gesellsch.  deutsch.  Naturforsch.  u.  Aerzte  in  Munster),  1912.  A 
report  of  650  cases  in  which  355  patients  were  adults  and  295  children.  There 
were  450  cases  of  closed  surgical  tuberculosis  and  200  cases  of  open  surgical 
tuberculosis.  In  the  cases  of  closed  surgical  tuberculosis  393  patients  were 
cured,  41  improved,  11  remained  stationary,  and  5  died.  Of  the  patients  with 
open  surgical  tuberculosis,  137  were  cured,  29  improved,  14  remained  sta- 
tionary, and  20  died. 

Rollier  and  Rosselet :  Sur  le  role  du  pigment  epidermique  et  de  la  chloro- 
phylle  (Bulletin  de  la  Soc.  des  sciences  nat.  1908). 

Rollier  and  Hallopeau  :  Sur  les  cures  solaires  directes  des  tuberculoses  dans 
les  stations  d'altitude.  Communication  a  l'Academie  de  Medecine,  Paris  (Bul- 
letin de  l'A.  d.  Med.,  1908,  page  422). 

Rollier  and  Borel :  Heliotherapie  de  la  tuberculose  primaire  de  la  conjonc- 
tive  (Rev.  med.  de  la  Suisse  romande,  20  avril  1912). 

Witmer,  T.  and  Franzoni,  A.:    Deutsch.  Zeitschrift  fur  Chirurgie,  No.  114. 

P.   F.   Armand-Delille:    L'Heliotherapie,   Masson   et    Cie,    Paris,    1914. 

P.  Vignard  and  P.  Jouffray :  La  Cure  Solaire  des  Tuberculoses  Chirurgi- 
cales,  Masson  et  Cie,  Paris. 


74  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

it  is  a  general  affection  which  requires  general  treatment.  Of  all  infectious 
diseases  it  is  the  one  in  which  the  individual  resistance  plays  a  deciding  part. 
Our  first  effort,  therefore,  is  directed  to  improve  general  conditions  and  thus 
to  bring  about  a  healing  of  the  local  focus  by  treatment  of  the  entire  system. 
A  rational  local  treatment  is  necessary  as  well,  provided  it  is  not  too  one- 
sided. 

Ill  cases  of  spondylitis,  or  Pott's  disease,  the  children  wear  jackets 
having  a  large  fenestrum  cut  anteriorly,  as  the  vertebrae  in  children 
are  not  much  further  removed  from  the  surface  of  the  abdomen  than 
from  that  of  the  back.  After  healing  is  verified  by  X-ray  a  celluloid 
corset  is  worn.  One  or  two  years  are  required  for  the  cure.  Plate 
29  shows  a  girl  thus  cured  of  pronounced  Pott's  disease  with  gib- 
bosity, and  paraplegia  and  muscular  atrophy.  There  was  complete 
healing  after  fifteen  months  of  the  solar  cure  which  the  illustration 
well  shows. 


CASES  OF  HIGH   ALTITUDE  TREATMENT 

As  illustrations  of  the  good  effect  of  high  altitude  treatment,  two 
cases  from  the  practice  of  the  late  Dr.  Charles  Theodore  Williams,, 
of  London,  may  be  cited.  They  were  both  cured  at  St.  Moritz. 
(6,000  feet). 

Miss  C,  aged  18,  was  first  seen  by  Dr.  Williams,  July  20,  1887. 
She  had  lost  a  sister  from  tuberculosis  and  she  had  a  history  of 
cough  and  expectoration  for  five  months  and  wasting  and  night 
sweats  for  two  months ;  total  loss  of  appetite  and  aspect  very  pallid. 
Slight  dulness,  crepitation  in  first  interspace  to  the  right.  Ordered 
to  St.  Moritz  for  the  winter.  In  the  spring  the  patient  spent  six 
weeks  in  Wiesen,  elevation  4,760  feet.  She  entirely  lost  her  cough 
and  expectoration,  gained  twenty-four  pounds  in  weight  and  became 
well  bronzed,  looking  the  picture  of  health.  Her  chest  increased 
enormously  in  circumference  and  measured,  on  full  expiration,  five 
inches  more  at  the  level  of  the  second  rib  than  before  she  left 
England.  She  stated  that  she  had  burst  all  her  clothes.  Careful 
examination  at  the  end  of  eleven  months,  when  these  later  notes 
were  taken,  showed  great  development  of  the  thorax  and  hyper-reso- 
nance everywhere,  but  no  abnormal  physical  signs.  After  more  than 
three  years  in  England  the  chest  measurement  had  somewhat  de- 
creased. 

Another  patient,  Miss  R.,  aged  21,  was  seen  in  November,  1879,- 
with  a  history  of  cough  with  expectoration,  loss  of  flesh,  night 
sweats,  pain  in  the  left  chest  and  evening  pyrexia  of  a  month's  dura- 


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SMITHSONIAN    MISCELLANEOUS   COLLECTIONS 


VOL.    63,     NO.     1,     PL.    29 


FIG.  1.  HELIOTHERAPY  AND  IMMOBILIZATION  IN  PLASTER  FOR  SURGICAL  TUBERCULOSIS.  BAL- 
CONY OF  DR.  ROLLIER'S  SANATORIUM,  "  LE  CHALET,"  LEYSIN,  SWITZERLAND.  THE  JACKETS 
HAVE  LARGE  OPENINGS  TO  ALLOW  ACCESS  OF  SUNLIGHT  TO  THE  DISEASED  SPINES.  SOME 
PATIENTS  IN   DORSAL   POSITION;  OTHERS  IN  VENTRAL  POSITION. 


FIG.  2.  CHILDREN  WHO  CAME  TO  DR.  ROLLIER  VERY  SICK  NOW  INDULGE  IN  WINTER  SPORTS.  NO 
CLOTHING  BUT  CAPS  AND  LOIN  CLOTHS.  NOTE  THE  MUSCULATURE  OF  THE  CHILDREN  FORMERLY 
SUBJECTS  OF  COXALGIA,  ARTHRITIS,   PERITONITIS  AND  ADENITIS.      . 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  75 

tion.  Dullness  and  deficient  breath  sounds  were  detected  close  to  the 
left  scapula.  After  three  years  of  unsuccessful  treatment  in  Eng- 
land, during  which  time  two  winters  were  spent  at  Hyeres,  on  the 
Mediterranean,  losing  ground  and  growing  thinner  and  showing  evi- 
dence of  commencing  disease  in  the  opposite  lung,  she  was  sent  for 
the  winter  to  St.  Moritz.  She  returned  the  following  May  vigorous 
and  well  bronzed,  having  taken  plenty  of  exercise,  skating,  walking, 
and  tobogganing.  She  had  lost  all  cough  and  had  gained  much 
strength.  The  chest  measurement  showed  an  increase  of  one  inch. 
The  whole  thorax  was  found  hyper-resonant  and  no  physical  signs 
of  consolidation  could  be  detected.  After  eleven  years  of  residence 
subsequently  in  England,  she  was  free  from  chest  symptoms. 

In  this  case,  notwithstanding  the  improvement  following  two 
winters  spent  at  Hyeres,  at  sea  level,  the  disease  was  not  arrested 
and  increased  the  following  year.  But  during  one  winter's  residence 
at  St.  Moritz,  elevation  6,000  feet  (diminished  atmospheric  pressure 
and  out-door  life  with  winter  sports),  there  was  complete  arrest  of 
the  disease,  as  the  experience  of  eleven  years  with  absence  of  phy- 
sical signs  testifies. 

There  is  a  wealth  of  clinical  material  to  show  the  advantages 
of  high  altitude  treatment  at  the  well-known  European  and  Ameri- 
can resorts.  Sir  Hermann  Weber,  of  London,  and  his  son,  Dr.  F. 
Parkes  Weber,  have  had  a  long  and  favorable  experience  in  the  treat- 
ment of  pulmonary  tuberculosis  in  high  altitudes  and  they  support 
Dr.  C.  T.  Williams  in  a  higher  estimate  of  treatment  of  this  disease 
at  high  elevations  as  contrasted  with  results  at  the  sea  level. 

Twenty-five  years  ago  Sir  Hermann  Weber  stated  that  out  of  106 
tuberculous  patients  sent  to  high  altitudes,  38  were  cured,  either 
permanently  or  temporarily,  16  were  stationary  or  but  slightly  im- 
proved and  10  deteriorated.  More  than  half  of  the  cases  in  the  first 
stage  were  cured. 

The  American  statistics  of  Drs.  Samuel  A.  Fisk,1  W.  A.  Jayne,2 
S.  E.  Solly,3  Charles  Denison  and  S.  G.  Bonney,  all  of  Colorado, 


1  Fisk,  Samuel  A.:  Concerning  Colorado  (Medical  News,  Sept.  16,  1899); 
Climate  of  Colorado   (Trans.  Amer.  Climat.  Ass..,  1888,  p.  11). 

2 Jayne,  W.  A.:  Climate  of  Colorado  and  Its  Effects  (Trans.  Amer.  Cli- 
mat. Ass.,   1888). 

3  Solly,  S.  E. :  Invalids  Suited  for  Colorado  Springs  (Trans.  Amer.  Climat. 
Ass.,  1888,  p.  34). 


y6  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

are  certainly  convincing  as  to  the  effect  of  high  altitude  treatment 
in  the  cure  of  pulmonary  tuberculosis.1 

Solly  said  in  1888,  "  Taking  the  medical  profession  throughout 
the  world,  it  is  unquestionable  that  a  large  majority  of  those  who 
have  made  a  study  of  the  subject  believe  that  where  a  change  is 
made,  a  change  to  an  elevated  country  is  the  most  likely  to  benefit 
a  consumptive." 

Solly  lived  for  thirty-three  years  in  Colorado  after  having  re- 
moved, as  a  tuberculous  invalid,  from  England.  Every  one  of  the 
physicians  mentioned  above  went  to  Denver  or  Colorado  Springs  as 
a  tuberculous  patient,  recovered  his  health  there,  acquired  a  repu- 
tation and  successful  practice  during  fifteen  to  thirty  years  of  resi- 
dence and  the  majority  are  alive  to-day  (1913).  Those  who  died 
succumbed  to  other  affections. 

According  to  Solly,  76  per  cent  of  all  patients,  good,  bad  and 
indifferent,  and  89  per  cent  of  those  in  the  first  stage  that  undergo 
climatic  treatment  in  Colorado  are  benefited.  Would  such  patients 
as  we  have  mentioned  have  derived  equal  and  as  lasting  benefit  at 
Alpine  Stations,  such  as  Davos  or  St.  Moritz,  which  have  a  corre- 
sponding altitude  and  an  equal  barometric  pressure  ?  Judging  from 
recorded  clinical  experience,  we  believe  that  they  probably  would 
have  done  equally  well.  We  can  never  know  absolutely.  Would 
they  have  done  equally  well  at  sea-level  or  at  very  moderate  altitude  ? 
None  of  the  physician-patients  whose  names  are  quoted  would  admit 
it. 

Dr.  Solly,  with  his  inimitable  humor  once  remarked,  "  If  I  were 
living  in  London  to-day,  I'd  be  dead."  In  all  human  probability  most, 
if  not  all  of  them,  are  fair  examples  of  the  curative  power  of  the 
Colorado  climate. 

Of  late  there  have  been  dissenting  voices,  challenging  some  of  the 
cardinal  principles  involved  in  the  altitude  treatment  of  tuberculosis. 
Not  only  altitude,  with  its  concomitant  rarefied  atmosphere,  but  even 
sunlight  itself  which  lightens  the  heart  of  every  invalid,  have  both 
been   denied  the  value  so  generally  assigned  them  in  tuberculo- 


1  Charles  Theodore  Williams :  Aerotherapeutics,  or  the  Treatment  of  Lung 
Diseases  by  Climate.  The  Lumleian  Lectures,  1893 ;  Macmillan,  1894,  pp. 
111-179. 

Charles  Denison :  Dryness  and  Elevation  the  Most  Important  Elements  in 
the  Climatic  Treatment  of  Phthisis  (Trans.  Amer.  Climat.  Ass.,  Vol.  1, 
1884,  p.  22). 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  JJ 

therapy.  These  discordant  notes  find  utterances  among  those  who 
have  been  compelled  to  treat  the  poorer  class  of  consumptives  in  our 
cities  at  the  seaboard  and  who  have  obtained  some  excellent  results. 
Stress  is  laid  on  the  beneficial  influence,  for  example,  of  cold.1  The 
fact  that  patients  improve  more  in  winter  than  in  summer  is  cited 
to  prove  that  "  cold  air  in  itself  seems  to  cure  in  a  manner  which 
nothing  else  can  accomplish.  *  *  *  Sunshine  is  not  essential — 
excellent  results  may  be  obtained  in  climates  where  the  sun  is  rarely 
seen.  Mere  outdoor  living  seems  to  be  the  essential  element,  and 
yet  there  does  not  seem  to  be  any  doubt  that  quicker  results  are  ob- 
tained in  the  cold  season  than  in  the  summer." 

EFFECT  OF  COLD  AIR 

There  is  truth  in  the  proposition  that  cold  air  is  better  for  the 
consumptive  than  heated  air.  It  is  usually  purer  and  is  unquestion- 
ably more  stimulating  to  the  vital  forces.  Warm  sleeping  rooms  are 
positively  bad  because  of  deficient  ventilation.  Warmth  debilitates 
and  opens  the  way  to  bacterial  invasion.  Hot  weather  is  relaxing, 
while  moderate  cold,  or  greater  cold  with  proper  safeguards,  acts  as 
a  tonic  and  fortifies  the  well  and  sick  alike  against  disease. 

The  good  effect  of  cold  air  in  tuberculosis  is  commonly  noted  by 
physicians  and  patients.  The  following  extract  from  a  letter  from 
a,  tuberculous  patient,  dated  Saranac  Lake,  New  York,  February 
19,  1908,  is  interesting: 

I  have  not  felt  the  cold  up  here  this  winter  as  I  feared  I  might,  although 
the  mercury  has  nearly  disappeared  on  one  or  two  memorable  nights.  460 
below  zero  is  the  coldest  I  have  seen  it  but  it  was  reported  500  below  in  the 
village.  I  am  quite  used  to  the  cold  now  as  I  sit  out  on  the  porch  all  day 
and  have  not  missed  a  day  yet;  but  there  is  one  redeeming  feature  about  the 
cold  up  here  and  that  is  that  zero  weather  does  not  seem  nearly  so  cold 
as  20°  above  in  Philadelphia.  I  really  do  not  begin  to  feel  it  until  it  gets  to 
200  below,  although  it  is  usually  too  cold  to  use  my  hands  even  in  milder 
weather.     J.   D. 

This  patient  was  22  years  old,  had  been  at  Saranac  fifteen  months 
and  is  reported  perfectly  well  and  weighs  180  pounds.  He  is  ap- 
parently cured.    He  remains  well,  Nov.,  1913. 


1  Editorial,  American  Medicine,  Philadelphia,  January  20,  1906. 
See  A.  D.  Blackader,  M.  D. :  The  Advantages  of  a  Cold,  Dry  Climate  in  the 
Treatment  of  Some  Forms  of  Disease   (N.  Y.  Med.  Journ.,  Aug.  3,  1912) . 


78 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 


The  minimum  temperature  at  Saranac  Lake  for  1912  was  — 320 
F.  on  January  25,  and  the  maximum  was  88°  F.  on  July  10.  The 
mean  temperature  was  40.98 °  F.  The  total  precipitation  was  43.19 
inches,  with  a  total  snowfall  of  124.24  inches.  Clear  days,  153 ; 
partly  cloudy,  JJ ;  cloudy,  136. 

The  extract  here  reproduced  from  a  letter  dated  Saranac  Lake, 
July,  1886,  is  interesting-.    It  was  addressed  to  the  author. 


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The  best  and  clearest  statement  of  seasonal  influence  on  body 
weight  of  consumptives  that  we  know  of  was  made  by  Dr.  N.  B. 
Burns,  of  the  North  Reading  State  Sanatorium,  Massachusetts.  His 
observations  are  based  on  one  thousand  patients  during  three  years. 
Fully  forty  per  cent  of  the  cases  admitted  to  this  sanatorium  were  of 
the  far  advanced  and  progressive  type.  It  was  noted  that  August, 
September  and  October  show  that  the  largest  percentage  of  patients 
gaining,  while  the  three  months  immediately  preceding  show  the 
opposite. 

Dr.  Burns  also  charted  the  aggregate  gain  in  pounds  of  the  male 
patients  treated  at  North  Reading,  December,  191 1  to  1912,  inclusive. 
There  was  a  rise  in  January  and  February,  191 2,  to  850  pounds  for 
76  patients  which  was  maintained  well  through  March  and  April. 


NO.    I 


AIR    AND   TUBERCULOSIS — HINSDALE 


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82  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

There  was  a  subsequent  sharp  decline  in  May,  the  index  dropping 
250  points.  This  fall  continued  without  interruption  in  June,  to  cul- 
minate July  11,  at  the  low  point  for  1912. 

The  conclusion  of  this  study  was : 

Phthisical  patients  are  apt  to  lose  rapidly  in  weight  and  general 
condition  in  May,  June,  and  the  first  two  weeks  in  July,  which  season 
constitutes  an  unfavorable  and  critical  period. 

Phthisical  patients  make  an  extraordinary  recovery  in  weight  and 
general  condition  in  the  month  of  August,  which  is  a  surprisingly 
favorable  time  of  the  year. 

August,  September,  January  and  February  are  the  most  propitious 
months  for  obtaining  successful  results  in  treating  pulmonary  tuber- 
culosis. 

Forced  feeding  in  the  unfavorable  season  seems  to  have  availed 
very  little  in  limited  number  of  cases  studied  at  -North  Reading. 

We  have  already  referred  to  the  beneficial  influences  of  the  Arctic 
summer  climate  (see  pages  39-42),  and  we  attributed  much  of  it 
to  the  perpetual  sunshine ;  consequently  we  cannot  agree  to  the 
illogical  statement  that  sunshine  is  not  essential.  We  believe  that  the 
"  Fireside  Cure  "  has  no  place  in  the  treatment  of  tuberculosis  and 
we  must  admit  that  whereas  only  a  few  years  ago  the  cold  air 
fiend,  who  slept  with  windows  wide  open  in  the  coldest  winter,  was 
considered  a  crank,  he  now  has  been  proved  to  be  the  only  sensible 
one  among  us.1 

EXPANSION    OF    THORAX    AT    HIGH    ALTITUDES 

Without  dwelling  further  at  this  time  on  the  effect  of  cold  air 
compared  with  warm  air  on  tuberculous  disease  (see  pp.  28,  40, 
71),  we  must  note  some  of  the  undeniable  effects  of  diminished 
atmospheric  pressure  on  physical  development  and  especially  on  the 
thorax  and  pulmonary  tissue. 

One  striking  change  is  the  expansion  of  the  thorax  in  various 
directions  and  a  corresponding  increase  in  the  mobility  of  the  tho- 
racic walls.  We  have  previously  referred  to  one  case  in  which  the 
circumference  increased  five  inches  during  a  residence  at  St.  Moritz, 
elevation  6,100  feet.  (See  page  74.)  Changes  of  from  one  to 
three  inches  are  more  commonly  noted  even  at  much  more  moderate 
elevations.     These  changes  are  conveniently  recorded  by  means  of 


1  American   Medicine,   loc.   cit. 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  83 

the  instrument  known  as  the  cyrtometer  which  gives  accurate  trac- 
ings for  recording  the  progress  of  the  patient.1 

Inasmuch  as  tuberculous  patients  in  whom  the  disease  is  actively 
progressing  show  a  shrinking  of  the  perimeter  pari  passu  with  the 
advance  of  the  disease,  and  those  who  are  recovering  show  an  in- 
creasing circumference,  it  is  a  fair  inference  that  the  physiologic 
increase  in  thoracic  measurements  due  to  residence  in  the  higher  alti- 
tudes is  an  advantage  in  the  prevention  and  treatment  of  pulmonary 
tuberculosis.  Man  is  not  adapted  to  live  permanently  at  altitudes 
above  13,000  to  16,000  feet  (4,000-5,000  meters),  but  at  somewhat 
lower  elevations  as,  for  instance,  at  10,000  feet  we  have  some  thriv- 
ing cities  such  as  Leadville  and  Cripple  Creek  in  Colorado,  and  Quito 
in  Equador,  elevations  10,000  and  9,350  feet  (3,000  and  2,850 
meters).  The  altitude  of  the  permanent  habitations  in  the  Ortler 
Alps  is  about  5,450  feet  (1,640  meters),  and  that  of  the  highest 
health  stations  from  5,000  to  7,000  feet  (Arosa).  It  is  a  well-known 
fact  that  the  Indians  of  the  Andes,  the  Swiss  guides,  the  Tyrolese 
hunters  and  other  mountain  dwellers  have  a  large  thorax  with  corre- 
spondingly deep  inspiratory  power  and  remarkable  endurance.2  The 
increased  respiration  and  the  quickening  of  the  circulation  promote 
health  and  vigor  in  mountain  races  and  comparisons  between  the 
highlanders  and  those  in  deep  and  flat  valleys  are  always  in  favor 
of  the  former.  All  observers  have  remarked  on  the  immunity  from 
disease,  and  especially  scrofulous  and  tuberculous  disease,  charac- 
teristic of  mountain  races,  provided  they  live  in  the  open,  avoid  over- 
crowding, have  sufficient  and  suitable  food  and  observe  ordinary 
hygienic  methods  of  life.  Failure  in  this  respect  provides  an  opening 
for  tuberculosis  which,  as  we  well  know,  is  the  scourge  of  the 
North  American  Indian  and  his  relatives  in  Mexico  and  South 
America.  Even  in  Quito,  that  city  of  remarkable  equability,  where 
it  is  perpetual  spring,  tuberculosis  has  effected  an  entrance,  and 
enters  largely  into  the  mortality  lists.3  In  Bogota,  South  America, 
in  La-Paz,  Mexico  (elevation  11,000  feet,  3,360  meters)  and  in  other 
densely  populated  towns  in  these  countries,  the  later  records  show 
increasing  numbers  of  cases  of  tuberculosis.     This  fact,  however, 


"See  Minor,  Charles  L. :  The  Cyrtometer:  A  Neglected  Instrument  of 
Pulmonary  Diagnosis  and  Prognosis  (Trans.  Amer.  Climat.  Ass.,  1903,  p. 
221).  ; 

'"Mexican  Indians,  though  of  medium  height,  have  unusually  large  and 
wide  chests,  quite  out  of  proportion  to  their  size."  Jourdanet. 

3Jacoby:    These  de  Paris,   1888.     Quoted  by  Huggard. 


84  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

should  not  afford  the  slightest  ground  for  controverting  the  general 
proposition  that  life  at  altitudes  of  from  3,000  to  6,000  feet  favors 
immunity  from  tuberculosis  and  the  cure  of  the  disease  in  suitable 
cases. 

CHOICE  OF  CASES  FOR  HIGH  ALTITUDE 

The  question  then  arises,  what  are  suitable  cases  for  altitude  treat- 
ment? What  kind  of  patients  may  be.  sent  to  stations  of  lower 
barometric  pressure? 

In  choosing  a  location,  the  late  Dr.  F.  I.  Knight,  of  Boston,  for- 
mulated some  opinions  based  on  his  long  experience.1  He  limited 
the  age  of  those  resorting  to  altitudes  to  fifty  years.  In  temperament 
he  preferred  the  phlegmatic  to  the  nervous,  with  an  irritable  heart, 
frequent  pulse,  and  inability  to  resist  cold;  and  with  the  latter  we 
must  be  careful  not  to  include  those  who  show  nervous  irritability 
from  disease,  not  temperament,  as  they  are  generally  benefited  in 
high  places.  As  regards  disease,  he  first  considered  cases  of  early 
infection  of  the  apices  of  the  lungs  with  little  constitutional  disturb- 
ance, and,  although  these  generally  do  well  under  most  conditions, 
yet  considerable  experience  assured  him  that  more  recover  in  high 
altitudes  than  elsewhere. 

It  is  best  to  begin  with  low  altitude  in  patients  with  more  advanced 
disease  showing  some  consolidation  but  no  excavation ;  also  when 
both  apices  or  much  of  one  lung  is  involved  and  the  pulse  and  tem- 
perature are  both  over  100. 

Hemorrhagic  cases,  early  cases  with  hemoptysis  and  without  much 
fever  are  benefited  by  high  altitudes.  Patients  with  advanced  dis- 
ease, those  with  cavities  or  severe  hectic  symptoms  should  not  be 
sent  to  high  altitudes.  A  small,  quiet  cavity  is  not  a  counter-indica- 
tion ;  hectic  symptoms  are  counter-indications. 

This  accords  with  the  latest  report  from  the  U.  S.  Public  Health 
Service  Sanatorium  at  Fort  Stanton,  New  Mexico,  altitude  6,231 
feet.  Dr.  F.  C.  Smith  reports  56  deaths  from  pulmonary  hemor- 
rhage in  a  total  of  524  patients  since  the  hospital  was  opened  in 
1899.  His  conclusion  is  that  pulmonary  hemorrhage  is  not  more 
frequent  at  high  altitude  than  at  sea  level,  but  the  results  are  perhaps 
more  often  serious,  especially  in  those  with  impaired  circulation.2 


1  Trans.   Amer.   Climat.  Ass.,   1888,  p.  50. 

"Public  Health  Reports,  U.  S.  Public  Health  Service,  No.  51,  by  F.  C. 
Smith,  Passed  Ass't  Surgeon,  Washington,  1910.  See  also  Report  No.  93, 
Washington,  1912. 


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NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  85 

Patients  in  an  acute  condition  should  not  be  sent.  Cases  of  fibroid 
phthisis,  in  Dr.  Knight's  opinion,  are  not  suitable.  Convalescents 
from  pneumonia  or  pleurisy  are  usually  well  suited  for  elevated 
regions.  Advanced  cases  of  tubercular  laryngitis,  if  good  local  treat- 
ment and  freedom  from  dust  can  be  obtained,  may  do  no  worse  in 
elevated  regions  than  elsewhere. 

In  cases  complicated  by  cardiac  dilatation  we  cannot  advise  alti- 
tude ;  but  a  cardiac  murmur  resulting  from  a  long-past  attack  of 
endocar.ditis  with  no  sign  of  enlargement  or  deranged  circulation 
should  not  prevent.  Nervous  derangements  of  the  heart  are  usually 
counter-indications. 

The  observations  made  at  the  United  States  Public  Health  Sana- 
torium at  Fort  Stanton,  New  Mexico,  by  Surgeon  F.  C.  Smith,  of  the 
service  are  commended  as  a  valuable  contribution  to  the  Relation  of 
Climate  to  the  Treatment  of  Pulmonary  Tuberculosis.  This  sana- 
torium is  open  to  sailors  in  the  merchant  marine  and  they  are  trans- 
ferred from  the  twenty-two  marine  hospitals  on  the  coasts  and 
rivers  to  this  admirable  inland  sanatorium.  It  was  found  that  the 
results  have  been  nearly  three  times  as  good  in  the  cases  which  left 
the  home  stations,  i.  e.,  the  local  marine  hospitals,  without  fever  as 
in  those  who  had  a  temperature  of  380  C.  (100.4°  F-)  or  more 
within  two  weeks  of  departure.  The  deaths  in  those  leaving  afe- 
brile were  to  those  leaving  with  fever  as  22  to  59 ;  the  arrests,  as 
19  to  yJ/2  ;  the  apparent  cures,  as  10  to  3.  Dr.  Smith  holds  that  the 
case  that  should  be  sent  to  a  distant  climate  immediately  upon  diag- 
nosis is  exceptional  and  he  also  adds  that  neglect  to  make  an 
early  diagnosis  does  not  warrant  precipitate  haste  in  sending  the  vic- 
tim away  when  it  is  finally  established.  The  psychologic  moment 
for  a  climatic  change  is  when  there  is  a  comparative  quiescence  of 
the  lung  process  under  treatment  at  home,  when  nutrition  is  im- 
proved and  further  improvement  is  slow  (Francine).  Climatic 
change,  however,  must  sometimes  be  made,  as  we  will  see  later  on, 
when  the  hoped  for  stage  of  quiescence  does  not  occur. 

Before  allowing  patients  with  pulmonary  diseases  to  go  long  dis- 
tances or  to  make  any  great  change  to  higher  altitudes,  some  caution 
should  be  given.  In  the  first  place,  patients  should  not  make  any 
physical  exertion  for  two  or  three  weeks  after  arrival.  The  air  may  be 
stimulating,  there  may  be  sights  to  see  and  many  dangerous  invitations 
given,  but  it  is  absolutely  necessary  that  the  patient  should  be  ad- 
justed to  the  new  atmospheric  conditions.  Acclimatization  is  neces- 
sary to  comfort  and  safety.  In  the  old  days  it  was  accomplished  by  the 
slow  ride  in  the  stage-coach  over  the  plains.  We  cannot  go  back  to  the 


86  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

old  methods,  and  therefore  we  must  exercise  greater  caution.  No  fe- 
brile case  should  be  sent  on  these  journeys  or  to  any  elevated  resort. 
Hemorrhage  is  not  a  counter-indication  to  a  change  of  altitude,  and 
it  is  not  any  more  liable  to  occur  at  five  to  six  thousand  feet  than 
at  sea-level.  However,  no  advanced  case  of  pulmonary  tuberculosis 
should  be  sent  away.  Financial  considerations  are  highly  important. 
Expenses  are  usually  underestimated,  and  the  want  of  sufficient 
means,  the  need  to  economize  as  regards  the  necessities,  not  to  speak 
of  the  luxuries,  of  life,  is  a  dreadful  handicap,  and  should  bar  out 
many  a  case  that  succumbs  for  want  of  the  very  comforts  he  had 
left  behind.  It  would  be  far  better  for  such  patients  if  they  should 
enter  some  special  hospital  or  sanitarium  for  consumption,  such  as 
are  found  in  most  of  our  Eastern  States. 

No  one  should  be  sent  away  without  definite  and  satisfactory 
knowledge  of  the  place  to  which  he  is  sent,  and  without  a  letter  of 
introduction  to  some  favorably  known  practitioner  containing  a  state- 
ment of  the  main  points  in  the  case. 

In  matters  of  climate,  as  in  many  other  fields,  it  is  the  man  behind 
the  climate  who  will  help  the  patient,  save  him  from  errors  and  in- 
discretions, advise  him  and  direct  him  as  to  local  surroundings,  and 
enable  him  so  to  live  that  his  disease  shall  be  arrested. 

Some  localities  favorable  for  tuberculous  patients  have  already 
been  mentioned.  Taking  the  country  as  a  whole  we  naturally  look 
to  the  elevated,  sparsely  settled  regions  of  Colorado,  New  Mexico, 
Wyoming,  Montana,  Nevada,  Utah,  Arizona  and  California.  The 
slopes  of  the  Rocky  Mountains  and  the  Great  Basin  are  justly  en- 
titled to  first  choice,  provided  always  that  other  safeguards  than 
climate  are  to  be  had  for  the  protection,  the  comfort  and  nutriment 
of  the  patient.  Texas,  especially  the  central  and  higher  western  por- 
tion, must  be  included  in  this  great  area.  Life  in  Texas  was  for- 
merly rather  too  rough  and  food  and  accommodations  were  too 
primitive  for  fastidious  people,  but  now  at  places  like  San  Antonio 
and  El  Paso,  these  defects  have  been  remedied.  The  winter  climate 
of  Texas  is  very  agreeable,  except  when  the  Texas  norther  descends 
and  holds  everything  in  an  icy  clasp.  However,  this  is  not  alto- 
gether a  disadvantage,  if  not  too  severe. 

Florida  suits  some  cases  of  phthisis.  The  interior  of  the  state  is 
sandy  and  the  winter  and  spring  climate  is  excellent.  The  culti- 
vation of  orange  groves  and  other  agricultural  features  of  the  state 
have  given  many  a  patient  a  profitable  occupation  that  he  would 
never  have  found  elsewhere. 


NO.    I  AIR    AND   TUBERCULOSIS — HINSDALE  87 

Thomasville,  in  Georgia,  sixteen  miles  from  the  Florida  line, 
and  Aiken  and  Camden,  in  South  Carolina,  have  long  had  a  reputa- 
tion for  the  relief  of  pulmonary  affections.  Asheville,  North  Caro- 
line, is  more  elevated  (2,300  feet)  and  has  an  excellent  "  all  the  year 
round  "  climate.  Special  attention  is  given  to  tuberculous  patients 
at  this  resort,  and  this  is  something  that  cannot  be  said  of  all  the 
good  places.  In  Pennsylvania,  suitable  places  are  found  in  the 
Pocono  Mountains,  at  White  Haven,  Kane,  Cresson,  Mont  Alto  and 
Hamburg.  In  New  Jersey,  there  are  Lakewood,  Brown's  Mills, 
Haddonfield,  Vineland,  and,  for  special  cases,  such  as  chronic  fibroid 
phthisis,  we  may  advise  Atlantic  City. 

In  New  York,  there  are  the  Adirondacks,  especially  the  vicinity 
of  Saranac ;  Loomis,  in  Sullivan  County,  where  there  is  an  excellent 
sanatorium.  In  New  England,  there  are  institutions  at  Rutland 
and  Sharon,  Massachusetts ;  Wallum  Lake,  Rhode  Island ;  Walling- 
ford,  Connecticut.  But,  as  we  have  said  before,  the  choice  of  a 
place,  whether  near  home  or  at  a  distant  point,  involves  all  the  ques- 
tions of  diagnosis,  of  temperament,  of  financial  resources,  all  of 
which  the  physician  must  weigh  as  conscientiously  as  though  his  own 
life  depended  on  it. 

Of  late,  English  physicians  have  been  making  more  extended  use 
of  the  higher  Alpine  resorts.  Among  these,  Davos  Platz,  altitude 
5,200  feet;  St.  Moritz,  6,000  feet;  Arosa,  6,100  feet;  and  Leysin, 
4,712  feet,  are  usually  chosen.  Their  chief  characteristics  are  an 
atmosphere  of  dry,  still,  cold,  rarefied  air ;  absence  of  fog,  few 
clouds  and  very  little  wind.  There  is,  therefore,  strong  sunlight 
with  a  grateful  warmth  in  the  sun's  rays. 

In  selecting  cases  for  treatment  by  change  of  climate,  we  must 
exercise  as  much  discrimination  as  in  applying  any  other  remedial 
measure.  Indeed,  more  caution  should  be  used,  for  the  patient  will 
pass  out  of  observation  and  in  most  cases  the  advice  given  involves 
the  most  vital  consequences. 

CHAPTER    V.    INFLUENCE    OF    INCREASED    ATMOSPHERIC 
PRESSURE;  CONDENSED  AIR 

Celsus,  in  treating  of  pulmonary  tuberculosis  in  the  first  century 
A.  D.,  advocated  a  change  of  climate  and  to  "  seek  a  denser  air 
than  one  lives  in."  * 

A  few  places  in  California  and  in  Asia  Minor  are  below  sea-level. 


1  De  Medicina,  Paris  edition,  Delahay,  1855. 


88  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.   63 

But  the  consequent  increased  atmospheric  pressure  in  these  localities 
is  not  in  itself  worthy  of  note.  Such  desolate  regions  as  the  Dead 
Sea,  the  Mojave  Desert,  Death  Valley,  and  Salton  Lake,  California, 
are  entirely  unsuited  for  the  tuberculous,  and,  for  obvious  reasons, 
all  subterranean  pressures  are  out  of  the  question.  Divers  and 
caisson  workers  become  anemic  and  hence  artificial  pressures  in- 
creased beyond  the  normal  at  sea  level  are  injurious. 

Even  the  natural  variations  in  atmospheric  pressure  at  any  given 
station  may  be  sufficient  to  have  some  appreciable  influence,  per  se, 
on  the  course  of  pulmonary  tuberculosis.  Changes  of  pressure  of 
20  mm.  (.7874  inches)  occasionally  take  place,  but  they  are  com- 
parable to  a  gradual  change  of  level  amounting  to  only  200  meters 
(656  feet),  and  it  has  been  assumed  that  no  appreciable  physiologic 
effects  can  be  attributed  to  these  gradual  alterations,  at  least  as  far 
as  tubercular  diseases  are  concerned.  Hann 1  and  Thomas  2  state 
that  in  experiments  with  pneumatic  chambers,  pressure  changes 
amounting  to  300  mm.  (11.8  inches)  a  day  have  been  produced 
without  causing  any  notable  injurious  effects  upon  the  sick  persons 
concerned  in  these  experiments. 

EFFECT   OF   BAROMETRIC    CHANGES   ON    THE   SPIRITS 

As  the  barometric  pressure  in  any  given  place  falls  the  cloudiness 
usually  increases,  the  temperature  rises,  the  wind  increases,  and 
precipitation  is  liable  to  occur ;  as  the  pressure  rises  the  skies  clear, 
the  temperature  falls  and  the  winds  shift  to  the  west  or  northwest. 
The  spirits  and  general  morale  of  all  patients  usually  improve  with 
a  rising  barometer  unless  prolonged  wind  storms  accompany  such  a 
change.  Whatever  improvement  accompanies  a  rising  barometer 
is  due  to  the  stimulus  of  cold  or  the  return  of  sunshine  and  dryer 
air. 

Dr.  Charles  C.  Browning,  of  Los  Angeles,  has  studied  the  effect 
of  some  atmospheric  conditions  on  tuberculous  patients.3  In  his 
first  report  it  appeared  that  unseasonable  or  very  sudden  changes 
in  temperature  influenced  temperature  of  patients,  while  equal  or 
greater  changes  occurring  slowly  did  not.  Of  hemorrhages  occur- 
ring in  groups  about  four  times  the  number  occurred  when  there 


1  Julius  Hann:    Handbook  of  Climatology,  Macmillan,  1903,  p.  71. 

2  Thomas,  in  Beitrage  zur  Allgemeinen   Klimatologie,   Erlangen,   1872. 

3  Trans.  American  Climatological  Ass.,  1908 ;  idem,  1913,  p.  189. 


NO.    I 


AIR   AND   TUBERCULOSIS — HINSDALE 


89 


AUGUST    1912 
DATE                 1     2  :  3     4    5     6    7     8    9    10    II     12 

13    14   15    16    17   18   19  20  21    22  23  24  25  26  27  28  29  30  31 

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Relation  of  pulmonary  hemorrhages  and  deaths  from  tuberculosis  to  barometric  pressure, 
temperature  and  humidity.    Courtesy  of  Dr.  C.  C.  Browning,  Los  Angeles,  Cal. 


9o 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 


SEPTEMBER     1912. 
D  AT  E                 1      2     3     4      5      6      7     8      9     10     II     12    13    14    15     16    17    18    19    20   21    22  23   24  25    26  27  28  29  30 

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Relation  of  pulmonary  hemorrhages  and  deaths  from  tuberculosis  to  barometric  pressure, 
temperature  and  humidity.     Courtesy  of  Dr.  C.  C.  Browning,  Los  Angeles,  Cal. 


NO.    I 


AIR   AND   TUBERCULOSIS — HINSDALE 


91 


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Relation  of  pulmonary  hemorrhages  and  deaths  from  tuberculosis  to  barometric  pressure, 
temperature  and  humidity.    Courtesy  of  Dr.  C.  C.  Browning,  Los  Angeles,  Cal. 


92 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 


JANUARY    1913 
DATE                1      2     3     4     5     6     7     6     9     10    II     12    13    14   15    16    17    18    19  20  21    22  23  24  25  26  27  28  29  30  31 

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Relation  of  pulmonary  hemorrhages  and  deaths  from  tuberculosis  to  barometric  pressure, 
temperature  and  humidity.    Courtesy  of  Dr.  C.  C.  Browning,  Los  Angeles,  Cal. 


NO.    I 


AIR    AND    TUBERCULOSIS HINSDALE 


93 


FEBRUARY    1913. 
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Relation  of  pulmonary  hemorrhages  and  deaths  from  tuberculosis  to  barometric 
pressure,  temperature  and  humidity.  Courtesy  of  Dr.  C.  C.  Browning,  Los 
Angeles,  Cal. 


94 


SM 


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Relation  of  pulmonary  hemorrhages  and  deaths  from  tuberculosis  to  barometric  pressure, 
temperature  and  humidity.    Courtesy  of  Dr.  C.  C.  Browning,  Los  Angeles,  Cal. 


NO.    I 


AIR    AND    TUBERCULOSIS HINSDALE 


95 


was  a  barometric  pressure  change  exceeding  .3  of  an  inch  within 
twenty-four  hours  than  when  the  change  was  less.  The  hemor- 
rhages appeared  to  be  more  frequent  if  there  had  been  a  change  in 
the  opposite  direction — a  sudden  fall.  The  cases  observed  were  all 
in  the  advanced  stage.  The  conditions  which  appear  to  influence 
groups  of  hemorrhages  and  deaths  are  barometric  pressure,  humidity 
and  cloudiness,  each  in  turn  appearing  to  be  the  most  prominent 


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Chart  showing  deaths  from  tuberculosis  in  the  Los  Angeles  County  Hospital 
and  in  the  city  of  Los  Angeles  in  1910.  Rainfall,  mean  monthly  temper- 
ature and  relative  humidity  are  also  shown.  Courtesy  of  Dr.  C.  C. 
Browning. 

index  in  exerting  a  limited  determining  influence.  This  is  shown  in 
the  two  charts  for  November  and  December,  19 12.  Dr.  Browning's 
paper  contains  charts  for  six  other  months. 

Dr.  Browning  notes  the  influence  of  fog  and  remarks  that  the 
"  high  fog  "  is  regarded  by  many  as  one  of  the  most  desirable  fac- 
tors of  the  Southern  California  climatic  condition.  It  is  not  fog 
in  the  generally  accepted  meaning,  for  this  "  light  veil  "  is  neither 
cold  nor  excessively  moisture  laden  ;  neither  is  it  high,  for  its  altitude 
is  less  than  a  thousand  feet. 


96  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

When  the  barometer  is  gradually  rising  and  the  humidity  slowly 
falling  and  the  sky  clear  or  clearing,  patients  are  pleasant,  in  some 
cases  jovial  and  inclined  to  be  optimistic  as  to  the  future. 

When  the  barometer  is  either  gradually  or  rapidly  falling  and  the 
humidity  rising  and  becoming  more  oppressive  as  the  hours  go  by, 
and  the  day  is  foggy  with  little  or  no  sunshine,  the  effect  on  patients  is 
entirely  different.  They  become  pessimistic,  cross  and  very  irrit- 
able. During  the  so-called  "  northers,"  when  the  barometer  falls, 
then  rises  rapidly  with  clear  weather  and  a  quick  drop  in  the  humid- 
ity as  from  75  per  cent  to  20  per  cent  in  twenty-four  hours,  there 
is  a  marked  drying  of  the  mucous  membrane,  causing  great  discom- 
fort in  some  and  comfort  in  others. 

ARTIFICIALLY    COMPRESSED   AIR 

Artificially  compressed  air  has  been  used  by  Oertel,  Simonoff  and 
Charles  Theodore  Williams  in  pulmonary  tuberculosis.  The  first 
two  claimed  great  improvement  resulting  from  its  use ;  but  Williams 
did  not  find  such  favorable  effects.1  In  nine  cases  submitted  to  the 
compressed  air  bath,  hemorrhage  was  brought  on  in  two  while  in  the 
bath ;  in  four  others  hemorrhage  occurred  but  could  not  be  distinctly 
connected  with  this  form  of  treatment.  There  was  usually  some 
gain  in  weight  and  diminished  cough  and  expectoration,  and  appar- 
ently the  respiration  became  freer  in  the  unaffected  portions  of  the 
lungs.  Beyond  the  opening  up  or  aeration  of  portions  of  the  lung 
which  had  not  been  brought  into  play  for  some  time,  there  seemed 
to  be  no  special  change  for  the  better.  Compressed  air  in  Williams's 
experience  did  not  facilitate  the  absorption  of  lung  consolidation  or 
infiltration. 

At  the  Brompton  Hospital  a  large  wrought  iron  chamber  was  con- 
structed about  ten  feet  in  diameter  by  eight  feet  in  height,  and  ac- 
commodated four  patients.  It  had  thick  glass  windows  and  a  closely 
fitting  door.  By  means  of  inlet  and  outlet  pipes  compressed  air  was 
introduced  and  allowed  to  escape.  The  outer  air  from  a  pure  source 
was  filtered  through  cotton  and  pumped  into  the  receiver.  The  pres- 
sure was  gradually  increased  after  the  patients  were  inside  the  tank 
until  it  reached  ten  pounds  or  two-thirds  of  an  atmosphere  above  the 
normal.  Half  an  hour  was  spent  in  increasing  the  pressure,  one  hour 
in  maintaining  it  at  the  highest  point  required,  and  half  an  hour  in 


1  Charles  Theodore  Williams  :  Compressed  Air  Bath  and  Its  Uses  in  the 
Treatment  of  Disease,  London ;  Smith,  Elder  &  Co.,  1885,  and  Aerotherapeu- 
tics,   Macmillan,   London,    1894,   p.    106. 


NO.    I  AIR    AND   TUBERCULOSIS HINSDALE  97 

reducing  it ;  so  that  two  hours  were  consumed  in  its  application 
therapeutically. 

A  practical  difficulty  was  encountered  in  keeping  the  compressed 
air  sufficiently  cool  to  be  comfortable,  owing  to  the  fact  that  air  invari- 
ably rises  in  temperature  during  compression  and  cools  during  rare- 
faction ;  so  that  in  warm  days  ice  had  to  be  used  about  the  reservoir. 

Von  Vivenot,  in  a  careful  series  of  experiments,  showed  that  the 
influence  of  compressed  air  on  the  respiratory  capacity  was  to  per- 
manently raise  it.  When  used  for  two  hours  every  day  it  is  found 
to  increase  daily  from  20  ccm.  to  30  ccm.  above  the  previous  day's 
record.  Von  Vivenot  took  122  compressed  air  baths  during  143  days 
and  his  respiratory  capacity  was  raised  from  3051  ccm.  to  3794  ccm. 
and,  in  compressed  air,  to  3981  ccm.  This  increased  capacity  was 
reached  in  three  and  a  half  months,  after  91  baths  and  was  after- 
ward maintained  at  practically  the  same  level.1 

An  increase  in  respiratory  capacity  has  been  noted  by  other  ob- 
servers, but  the  respiration  rate  is  always  lowered  and  in  almost  all 
cases  there  is  a  similar  lowering  of  the  pulse  rate. 

PNEUMATIC    CABINET 

These  experimental  results  naturally  appealed  to  phthisiologists 
and  patients  were  treated  at  Brompton,  as  we  have  mentioned,  and 
in  the  United  States  by  means  of  Ketchum's  pneumatic  cabinet  or 
similar  devices.  There  is  no  doubt  but  that  the  method  was  given 
a  fair  trial,  but  it  has  been  found  wanting.  The  pneumatic  cabinets 
installed  at  considerable  expense  at  the  Loomis  Sanitarium  at  Liberty, 
at  the  Rush  Hospital  in  Philadelphia  and  at  Saranac,  are  rusting 
away  or  consigned  to  the  scrap  heap.  The  simpler  and  more  natural 
method  of  outdoor  life  is  found  much  more  safe,  rational  and  effect- 
ive.2 

See  J.  Solis  Cohen :  The  Use  of  Compressed  and  Rarefied  Air  as  a 
Substitute  for  Change  of  Climate  in  the  Treatment  of  Pulmonary  Phthisis. 
(Trans.  Amer.  Climat.  Ass.,  Vol.  1,  1885). 

V.  Y.  Bowditch :  Ten  Months  Experience  with  Pneumatic  Differentiation, 
ibid.,  1886,  47. 

A.  S.  Houghton,  Journ.  Amer.  Med.  Ass.,  Nov.  7,  1885. 

C.  E.  Quimby,  Trans.  Amer.  Climat.  Ass.,  Vol.  9,  p.  33. 

Isaac  Hull  Piatt,  Trans.  Amer.  Climat.  Ass.,  Vol.  3,  p;  76. 


1  Paul  Bert,  op.  cit.,  p.  439. 

Huggard,  W.   R. :    Handbook  of  Climatic  Treatment,  p.   109. 

2  At  Sharon  .Sanatorium  it  is  still  used  in  some  cases  as  a  means  of  calis- 
thenics  for  the  chest  and  is  thought  to  be  of  value. 


98  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

Tiegel,  New  Yorker  Medicinische  Presse,  April,  1887. 

E.   L.   Trudeau,  Trans.  Amer.   Climat.  Ass.,   1886,  p.  41. 

Ketchum :    Physics  of  Pneumatic  Differentiation   (Medical  Record,  Jan.  9, 


Waldenburg,  Pneumatische  Behandlung,  Berlin. 
J.  T.  Whittaker,  Gaillard's  Med.  Journ.,  August  1885,  p.  208. 
Herbert  F.  Williams,  Journ.  Amer.  Med.  Ass.,  Aug.  14,  1885. 
Herbert  F.  Williams,  Trans.  Amer.  Climat.  Ass.,  1886,  p.   17. 
B.    F.    Westbrook,    Trans.    Amer.    Climat.    Ass.,    1887,    P-    I02- 

ARTIFICIAL    HYPEREMIA 

We  must  here  refer  to  an  important  advance  in  the  treatment  of 
surgical  tuberculosis  in  which  artificial  changes  in  the  atmospheric 
pressure  play  a  prominent  part.  Prof.  Bier,  of  Bonn,  first  used  his 
famous  method  in  treating  tuberculosis  of  joints;  he  used  the 
"  Staaungsbinde."  He  also  uses  cupping  glasses  of  various  shapes 
so  that  they  may  be  applied  to  various  parts.  The  rarefaction 
of  «the  air  is  accomplished  by  a  rubber  ball,  or  a  pump,  according 
to  the  size  of  the  glass.  After  opening  tuberculous  lymphatic  glands 
and  tuberculous  abscesses  in  connection  with  joints,  the  cupping 
glasses  are  applied  and  the  claim  is  made  that  this  process  avoids 
mixed  infections.  Tampons  and  drains,  also,  are  found  to  be  unnec- 
essary. 

In  treating  a  member,  for  instance  the  hand,  Bier  uses  a  glass 
cylinder  provided  with  a  cuff  and  a  rubber  band,  so  that  the  whole 
hand  is  hermetically  sealed  and  by  means  of  the  pump  the  air  is 
partially  exhausted.  By  similar  apparatus  Prof.  Bier,  Dr.  V. 
Schmieden,  Dr.  Willy  Meyer,  Ewart,  and  others  all  over  the  world 
have  treated  successfully  cases  of  surgical  tuberculosis  so  that  the 
method  has  an  established  place  in  tuberculo-therapy.1 

CHAPTER   VI.    ARTIFICIAL    PRESSURE;    BREATHING 
EXERCISES 

Radical  differences  of  opinion  exist  as  to  the  use  of  artificial  varia- 
tions of  pressure,  or  pneumatic  differentiation,  in  pulmonary  tubercu- 
losis and  also  as  to  the  larger  question  as  to  whether  the  diseased 
lung  should  be  set  at  rest  or  invited  to  expand. 

The  respiration  of  artificially  compressed  or  rarefied  air  for 
limited  periods,  such  as  half  an  hour  or  two  hours,  has  been  con- 
sidered, but  this  form  of  pulmonary  gymnastics  has  given  way  to 


1  August  Bier :    Hyperasmie  als  Heilmittel,  5th  edition.     Prof.  Bier  advises 
a  long  continued  residence  at  the  seashore  in  cases  of  surgical  tuberculosis. 


NO.    I  AIR    AND   TUBERCULOSIS HINSDALE  99 

more  natural  methods  of  accomplishing  the  results  aimed  at.  The 
judicious  use  of  exercises  has  been  advocated  for  centuries  and  this 
plan  of  treatment  has  passed  through  most  interesting  phases,  long 
advocated,  then  condemned  and  later  revived.  Some  of  the  recent 
advocates  of  exercise  by  graduated  labor  invoke  the  very  latest 
knowledge  of  the  pathology  of  tuberculosis  in  support  of  this  method. 

The  bad  effects  of  exercise  on  tuberculous  patients  at  the  well- 
known  climatic  stations  have  been  widely  commented  on  and  number- 
less histories  of  patients  going  to  their  death  when  caution  might 
have  saved  them  are  on  record.  Patients  going  from  the  lower  ele- 
vations to  altitudes  of  five  and  six  thousand  feet  do  not  seem  to 
realize  at  first  how  necessary  are  rest  and  thorough  acclimatization 
for  their  safety  during  the  earlier  weeks  or  months  of  treatment. 
The  higher  stations  are  natural  gymnasia  where  diseased  lungs  may 
be  trained  or  overtrained ;  where  accidents  may  happen  to  the  inex- 
perienced and  rash,  or  even  to  the  old  time  expert  if  he  neglects  to 
exercise  proper  judgment.  No  fall  from  the  trapeze  is  more  fatal 
in  its  effect  than  some  mountain  expedition  or  other  adventure  by 
the  tuberculous  patient.  Dr.  Solly  was  wont  to  say  that  nowhere  is 
the  invalid  fool  more  quickly  punished  for  his  folly  than  in  Colorado. 

We  are  concerned,  at  present,  with  exercise  as  it  relates  to  the 
breathing  habit  and  the  aeration  of  the  diseased  lung.  Exercises 
and  improved  breathing  habits  can  be  carried  out  and  acquired  at  the 
sea-level  or  at  higher  elevations.  We  believe  that  at  the  moderate 
or  higher  altitudes  breathing  exercises  are  more  effective  for  good 
and  tend  more  fully  to  develop  the  thoracic  movements  and  capacity 
than  at  the  lower  levels  (see  page  62).  Minor  has  recently  reviewed 
this  subject  in  a  paper  or  the  "  Use  and  Abuse  of  Pulmonary  Gym- 
nastics in  the  Treatment  of  Tuberculosis  "  and  holds  that  they  are 
beneficial  in  properly  selected  cases.  That  such  measures  are  abused 
by  those  who  use  them  indiscriminately  and  unintelligently  we  all 
know. 

ATMOSPHERIC   COMPRESSION   OF  .LUNG 

Fifteen  years  ago  Cornet  came  out  strongly  against  exercises  and 
others  of  experience  take  even  more  radical  ground.  The  principle 
of  rest  has  been  carried  to  such  an  extreme  that  surgical  measures, 
such  as  strapping  the  affected  side  to  insure  complete  immobilization, 
have  been  adoped.1    The  most  radical  measure  was  the  introduction 


Charles  Denison,  Trans.  Amer.  Climat.  Ass.,  Vol.  21,  1905. 


100  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.   63 

into  the  pleural  cavity  of  nitrogen  gas,  or  atmospheric  air,  so  as  to 
compress  the  lung  and  prevent  as  nearly  as  possible  all  motion.  The 
credit  for  devising  this  operation  and  first  performing  it,  belongs  to 
Forlanini,  but  it  was  first  practiced  in  America  by  Dr.  John  B. 
Murphy,1  of  Chicago,  and  has  been  repeatedly  used  by  many  others 
in  Europe  and  America,  including  the  late  Dr.  Henry  P.  Loomis,2 
Dr.  Cleaveland  Floyd  and  Dr.  Samuel  Robinson,  of  Boston,  Dr.  L. 
Brauer,  Prof.  T.  Beneke,  of  Hamburg,  Dr.  H.  L.  Barnes  and  Dr. 
F.  T.  Fulton,  of  Rhode  Island. 

ARTIFICIAL   PNEUMOTHORAX 

Prof.  Theodore  Beneke,  of  Hamburg,  says3  that  Forlanini  con- 
ceived the  idea  of  placing  the  affected  lung  at  rest  by  artificial 
pneumothorax  as  early  as  1882  ;  he  put  it  in  practice  in  1888  ;  Brauer 
and  Ad.  Schmidt  performed  it  in  1906.  Murphy  seems  to  have 
developed  his  operation  without  any  knowledge  of  Forlanini's  work. 
The  operation  has  been  performed  in  Germany,  according  to  Beneke, 
by  hundreds  of  physicians  on  several  thousand  patients.  The  opera- 
tion is  meeting  with  great  favor  in  America.4 

The  clinical  observation  that  the  occurrence  of  pleuritic  effusion 
in  tuberculous  cases  was  followed  by  an  arrest  of  the  symptoms  of 
the  primary  disease  if  the  effusion  were  left  undisturbed;  and, 
further,  the  unfavorable  results  which  follow  tapping  in  other  cases, 
or  when  later  adopted  in  cases  of  quiescent  during  the  presence  of 
the  effusion  led  to  this  method  of  artificially  producing  immobility. 
Pleuritic  effusion  is  intimately  connected  with  pulmonary  tuberculo- 
sis in  a  majority  of  cases  and,  if  not  purulent,  should  probably  be 
left  undisturbed. 

Loomis  followed  Murphy's  technique,  using  a  special  apparatus 
for  the  injection  of  pure  nitrogen  gas  by  means  of  which  from  fifty 


1  John  B.  Murphy :  The  Surgery  of  the  Lungs  ( Journ.  Amer.  Med.  Ass., 
1898).  Also  Surgical  Clinics  of  Dr.  John  B.  Murphy,  December,  1913.  W.  B. 
Saunders  Co.,   Phila. ;   also  Interstate   Medical  Journ.,  March,    1914. 

2  Henry  P.  Loomis :  Some  Personal  Observations  on  the  Effects  of  Intra- 
pleural Injections  of  Nitrogen  Gas  in  Tuberculosis  (Trans.  Amer.  Climat. 
Ass.,   1900;   Med.   Record,   Sept.  29,   1900). 

This  method  was  first  proposed  by  Prof.  Carlo  Forlanini,  of  Pavia,  Italy, 
at  the  International  Medical  Congress,  Rome,  1894. 

3  Ueber  den  kunstlichen  Pneumothorax,  "  Tuberculosis."    Berlin,  Nov.,  1913. 

4  See  article  by  Dunham  and  Rockhill,  with  discussion  by  C.  L.  Minor, 
Journ.  Amer.  Med.  Ass.,  Sept.  13,  1913. 


NO.    I  AIR   AND   TUBERCULOSIS HINSDALE  IOI 

to  two  hundred  cubic  inches  were  introduced  into  the  pleural  cavity 
on  the  affected  side1 

The  nitrogen  gas  introduced  into  the  pleural  cavity  does  not  re- 
main long  without  being  absorbed,  and  in  order  to  keep  the  lung 
immobilized  for  six  months  or  more,  repeated  injections  are  required. 
When  ordinary  atmospheric  air  gains  entrance  to  the  pleural  cavity 
it  constitutes  the  condition  known  as  pneumothorax,  and  if  the  pneu- 
mothorax becomes  closed,  the  oxygen  steadily  diminishes  and  finally 
disappears,  the  carbon  dioxide  decreases  and  the  last  element  to 
disappear  is  the  nitrogen.  This  fact  has  been  determined  by  chemical 
analysis  by  Dory,  Bouveret,  LeConte,  Ewald  (Loomis) .  The  respira- 
tions, are  always  increased  after  the  injections  and  the  pulse  rate  is 
lowered.  A  notable  effect  in  Dr.  Loomis'  cases  was  the  absolute  con- 
trol of  pulmonary  hemorrhage  in  cases  where  all  other  measures 
failed. 

Dr.  Loomis'  experience  in  eighteen  cases  treated  by  injections 
of  nitrogen  gas  was  uniformly  favorable,  although  not  curative. 
Probably  the  fact  that  pulmonary  hemorrhage  is  controlled  is  the 
chief  value  of  the  method,  though  gain  in  weight  followed  the  adop- 
tion of  this  measure  in  all  the  cases. 

SONG  CURE 

One  method  of  pulmonary  exercise  lately  advocated  for  tubercu- 
lous patients  is  by  singing.2  Singing  invokes  correct  nasal  breath- 
ing and  a  maintenance  of  the  elasticity  and  proper  expansion  of  the 
chest.  The  necessary  breathing  exercises  promote  an  increased  func- 
tional activity  of  all  parts  of  the  lungs,  including  the  apices  where 
tuberculosis  usually  first  becomes  evident.  It  is  here  that  expansion 
is  most  limited  and  the  prevalent  opinion  is  that  this  comparative 
inactivity  is  a  strong  factor  in  the  tendency  of  the  disease. 

The  "  song  cure  "  may  be  suitable  in  some  cases  of  pulmonary 


*For  a  good  description  of  the  latest  apparatus  and  a  discussion  of  the 
most  approved  methods  see  articles  by  Harry  Lee  Barnes  and  Frank  Taylor 
Fulton,  and  by  Samuel  Robinson  and  Cleaveland  Floyd,  Transactions  of  the 
American  Climatological  Association,  1913,  pp.  160-188,  and  191 1,  pp.  289-383. 
A  bibliography  is  given  in  Transactions,  1913,  p.  170. 

See  also  Trans.  American  Sanatorium  Association,  8th  spring  meeting,  p. 
16.  Discussion  by  H.  D.  Chadwick,  W.  A.  Griffin,  E.  S.  Bullock,  G.  W.  Hol- 
den,  J.  J.  Lloyd,  Jr.,  L.  Brown,  J.  Roddick  Byers. 

See  also  Samuel  Robinson,  "  Practical  Treatment,"  edited  by  Musser  and 
Kelly,  W.  B.  Saunders  Co.,  Philadelphia,  1911,  Vol.  3,  p.  254. 

aDrs.  Leslie  and  Horsford,  The  Hospital,  London,  Jan.  25,   1908. 


102  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

tuberculosis,  but  in  laryngeal  cases  it  would  be  counter-indicated. 
Its  practice  in  pulmonary  cases  has  not  been  adopted  to  any  very 
great  extent ;  but  it  would  seem  to  have  some  advantages  as  it  does 
not  involve  great  muscular  fatigue. 

It  is  well  known  that  public  speakers  with  pulmonary  tuberculosis 
cannot  continue  this  practice  with  impunity.  Their  tendency  to 
attempt  to  increase  their  weakening  vocal  powers  by  forcing  the  air 
outward  has  a  bad  influence  on  the  lungs.  Bad  habits  of  speaking 
and  lack  of  training  are  probably  accountable  for  these  bad  results. 
Artistic  breathing  should  be  cultivated  and  all  public  speaking  in 
crowded  and  badly  ventilated  halls  should  be  avoided.1  Knopf  refers 
to  cases  of  phthisis 1  which  had  even  passed  the  incipient  stage 
and  were  cured  after  following  the  occupation  of  street  singer  or 
speaker.  He  cites  the  case  of  an  English  lady  who  became  an 
evangelist,  addressing  crowds  of  people  every  night  in  open  air  meet- 
ings and  who  was  actually  cured  of  her  tuberculous  disease  after 
following  this  calling  for  a  year. 

Our  own  experience  leads  us  to  believe  this  to  be  an  exceptional 
result.  Having  had  some  experience  in  treating  members  o£  the 
Salvation  Army  in  various  grades  of  the  service,  the  impression 
gained  was  that  tubercular  disease  was  quite  common  among  them 
and  that  their  life  of  exposure,  unhygienic  quarters,  insufficient  food 
and  excessive  use  of  the  voice  rendered  them  an  easy  prey  to  con- 
sumption. The  voice  is  almost  always  over-strained  and  hoarse  and 
the  open  air  life  the  members  lead  is  accompanied  by  hardships 
which  over-balance  any  favorable  features  in  their  nomadic  exist- 
ence. 

Open  air  singing,  properly  employed,  as  in  the  German  Army, 
is,  no  doubt,  beneficial.  This  should  be  encouraged  by  all  military 
authorities.  It  relieves  the  tedium  of  the  march  and  invigorates  the 
soldier.  Barth,  of  Koslin,  has  made  a  thorough  study  of  the  effects 
of  singing  on  the  action  of  the  lungs  and  heart,  on  diseases  of  the 
heart,  on  the  pulmonary  circulation,  on  the  blood,  the  vocal  appara- 
tus, the  upper  air  passages,  the  general  health,  the  development  of 


1  George  Hudson  Makuen :  Artistic  Breathing  (Philadelphia  Medical  Jour- 
nal, Sept.  3,   1898). 

2  S.  A.  Knopf :  Respiratory  Exercises  in  the  Prevention  and  Treatment 
of  Pulmonary  Diseases  (Johns  Hopkins  Medical  Bulletin,  Sept.  1901). 

See  also  John  H.  Pryor,  Deep  Breathing  as  a  Therapeutic  and  Preventive 
Measure  in  Certain  Diseases  of  the  Lungs  (Trans.  Amer.  Climat.  Ass.,  Vol. 
22,  1906,  p.  251). 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  103 

the  chest,  on  metabolism  and  on  the  activity  of  the  digestive  organs, 
and  has  come  to  the  conclusion  that  singing  is  one  of  the  exercises 
most  conducive  to  health.      (Knopf.) 

CHAPTER  VII.    FRESH  AIR  SCHOOLS  FOR  THE  TUBERCULOUS; 

VENTILATION 

Under  the  name  of  "  Waldschule  "  these  have  recently  been  estab- 
lished in  Germany.  The  first  was  opened  at  Charlottenburg,  Berlin, 
August  1,  1904,  and  closed  its  first  term  October  29th  of  the  same 
year  with  120  scholars.  The  results  of  the  first  year  were  very 
encouraging,  the  average  increase  in  the  weight  of  the  children 
was  five  pounds,  and  the  Forest  School  has  been  regularly  opened 
each  year. 

The  credit  of  its  establishment  belongs  to  the  "  Vaterlandischer 
Frauenverein "  of  Charlottenburg.  This  patriotic  association  of 
women  selected  children  either  suspected  of  tuberculosis  or  with 
the  disease  already  established  for  the  Forest  School.  In  this  way 
educational  facilities  are  provided  for  children  whose  condition  ren- 
ders them  unsuitable  for  the  public  schools  and  at  the  same  time 
avoids  the  necessity  of  sending  them  to  sanatoria  where  there  is  little 
or  no  provision  for  teaching. 

At  Charlottenburg  they  put  up  so-called  "  Doecker  barracks  "  or 
transportable  buildings  of  light  construction.  There  was  one  school 
barrack,  containing  two  class-rooms  and  one  teachers'  room.  The 
second  barrack  was  used  for  household  purposes.  There  was  also 
an  open  "  liege-halle "  towards  the  south  where  the  children  may 
remain  during  bad  weather.  A  light  frame  structure  contains  wash 
rooms  and  a  bath-room  with  tub  and  douche.  Three  schoolmasters 
and  one  schoolmistress  give  instruction.  The  children  were  dis- 
tributed in  six  classes  of  about  twenty  each.  This  is  smaller  than 
in  the  public  schools  where  there  are  from  forty-five  to  sixty  in  a 
class.    The  sessions  never  lasted  over  two  hours  continuously.1 

This  school  has  now  grown  so  as  to  accommodate  240  children. 

A  second  school  is  located  in  M.-Gladbach  in  the  Rheinprovinz. 
It  was  opened  in  1906  for  sixty  children  between  eight  and  fourteen 
years  of  age. 

A  third  one  is  in  Muhlhausen,  Reichslande,  Elsass-Lothringen, 
Southwest  Germany.  It  was  opened  in  1906  and  the  physician  in 
charge  is  Dr.  Bienstock. 


1  For  further  particulars  of  this  school,  see  article  by  Dr,  J.  Nietner,  Tuber- 
culosis,   May,    1905. 


104  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

A  fourth  is  the  Forest  School  in  the  Victoria  Louise  Children's 
Sanatorium  at  Hohenlychen.  It  was  established  August  i,  1903. 
Pastor  Mickley  is  in  charge.  ■  These  are  the  pioneer  schools  and 
many  others  have  since  been  established. 

The  most  successful  private  open  air  schools  in  Germany  are 
conducted  by  Prof.  Dr.  Gustav  Pannwitz,  the  honorary  secretary 
of  the  International  Association  for  the  Prevention  of  Tuberculosis. 
They  are  situated  at  Hohenlychen,  about  two  hours  by  rail  from  Ber- 
lin, near  Templin,  on  the  hilly  plateau  which  is  called  the  "  Mecklen- 
burgisch — Pommersche — Seenplatte,"  between  the  East  Sea  and 
Spree  Rivers.  There  are  extensive  forests  of  fir,  a  large  lake  with 
an  island  of  240  acres  belonging  to  the  school.  It  is  conducted  on 
the  most  modern  hygienic  principles. 

An  open  air  school  was  established  at  Bostall-Heath,  near  Wool- 
wich, England,  in  1907;  in  France,  at  Lyons,  Vincennes  and  Bou- 
logne ;  in  Switzerland,  at  Lausanne,  open  from  June  5  to  Septem- 
ber 23,  at  Zurich  and  Geneva.  The  "  Rayon  de  Soleil  "  at  Geneva,  is 
for  very  young  children ;  so  also  "  Les  Oisillons  "  at  Lausanne. 

In  the  United  States  the  first  fresh  air  school  for  tuberculous 
children  was  established  in  Providence,  Rhode  Island.  Dr.  Ellen  A. 
Stone  and  Dr.  Mary  S.  Packard  had  a  small  day  camp  during  the 
summer  of  1907  for  children  suspected  of  having  tuberculosis.  They 
soon  became  convinced  that  a  fresh  air  school  ought  to  be  started 
for  the  benefit  of  the  tuberculous  children  of  Providence  and  they 
asked  the  help  of  Dr.  Jay  Perkins,  Chairman  of  the  Providence 
League  for  the  Suppression  of  Tuberculosis  in  getting  a  single 
small  school,  necessarily  ungraded,  for  those  children,  arranged 
so  as  to  approximate  an  out  of  door  school.  At  the  camp  which  these 
physicians  had  been  conducting  there  were  about  ten  children  who 
would  soon  have  to  go  back  to  the  ordinary  schools  or  else  would 
be  at  home  in  close  rooms. 

In  response  to  this  appeal  Dr.  Perkins  enlisted  the  sympathy  of  the 
Superintendent  of  Schools,  Mr.  Walter  H.  Small,  and  with  Judge 
Rueckert  and  Dr.  Charles  V.  Chapin,  the  school  committee  estab- 
lished the  first  fresh  air  public  school  in  America. 

A  school  house  not  then  in  use  and  centrally  located  was  requested 
for  use  and  granted,  and  the  necessary  changes  were  made.  The 
result  was  that  they  had  to  begin  with  a  room  on  the  second  floor 
the  full  size  of  the  building,  about  40  by  25  feet,  with  windows  on 
three  sides.  The  brick  wall  on  one-half  of  the  southerly  side  was 
removed  and  windows  substituted,  these  windows  extending  from 
near  the  floor  to  the  ceiling,  with  hinges  at  the  top  and  pulleys  ar- 


<  Q 

-I  M- 

0  o 

1  in 
O  <» 


NO.    I  AIR    AND    TUBERCULOSIS — HINSDALE  1()5 

ranged  so  that  the  lower  end  can  be  raised  to  the  ceiling,  thus  leaving 
this  half  of  the  room  completely  open  to  the  south.  Each  school 
desk  and  its  accompanying  seat  is  arranged  on  an  individual  wooden 
support  so  that,  while  stationary  as  regards  each  other,  each  desk 
and  seat  can  be  moved  as  desired,  and  thus  any  arrangement  of  seats 
may  be  made.  The  school  is  an  ungraded  one  ( the  ages  running 
from  7  to  13  years),  and  as  such  limited  to  25  pupils.  The  school 
hours  are  from  9  to  11.45  a-  m-  an(l  Irom  r45  to  3-3°  P-  m>  w'tn  a 
recess  from  10.15  to  I045-  Towards  the  end  of  this  recess  each 
pupil  is  served  a  cup  of  hot  soup.  Each  pupil  has  a  sitting-out  bag 
of  the  standard  type  and  in  very  cold  weather  has  a  hot  soapstone 
in  the  bottom  o'f  the  bag.  In  the  end  of  the  room  not  open  to  the 
south  a  good  fire  ic  kept  going,  thus  partially  warming  the  air  and 
keeping  that  end  of  the  room  moderately  warm,  the  pupils'  seats  all 
being  in  the  other  end. 

One  interesting  feature  in  connection  with  the  school  is  that, 
though  these  children  come  from  poor  homes  and  there  has  been  an 
extensive  epidemic  of  "  colds  "  in  winter,  especially  affecting  the 
nose  and  throat,  no  child  in  the  school  has  had  even  a  "  cold  in  the 
head."  On  being  enrolled,  each  child  is  weighed,  measured,  and 
the  hemoglobin  tested.  The  League  furnishes  the  sitting-out  bags 
and  soapstones  and  some  clothing,  the  city  paying  all  other  expenses. 

Thus  the  credit  for  suggesting  the  school  belongs  to  Drs.  Packard 
and  Stone,  but  the  work  was  developed  and  carried  on  through  the 
efforts  of  the  League.  Most  of  the  children  for  the  school  are 
selected  in  the  first  instance  by  the  head  tuberculosis  nurse  and  sec- 
ondly by  the  physicians  on  the  League  Committee.  All  of  them 
are  from  within  walking  distance  of  the  school.  Dr.  Stone  is  one 
of  the  Medical  Inspectors  of  the  Public  Schools  and  the  other  Medi- 
cal Inspector,  Dr.  Charles  E.  Hawkes,  was  added  to  the  committee. 

Providence  was  the  first  city  in  the  country  to  establish  special 
schools  for  the  mentally  deficient  and  the  school  department  is  to  be 
highly  complimented  because  of  the  enthusiasm  and  energy  with 
which  they  took  up  the  establishment  of  a  special  school  for  the 
physically  deficient  as  soon  as  the  matter  was  presented  to  them. 

This  Fresh  Air  School  in  Providence  was  opened  on  January  27, 
1908,  with  ten  pupils,  and  soon  twenty  were  enrolled.  Hot  soap- 
stones,  sitting-out  bags,  hot  drinks  at  recess,  frequent  trips  to  the 
stove,  breathing  exercises,  marching,  bending  movements,  and  uni- 
form work  in  singing  are  prominent  features  of  the  pioneer  fresh-air 
school   in   America.1 


1  Ellen  A.   Stone,   M.  D.,  Journal  of  the   Outdoor  Life,   May,    ic 


Io6  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

The  instruction  of  children  at  the  Sea  Breeze  Hospital  for 
Tuberculous  Children  at  Coney  Island  is  provided  by  the  Board  of 
Public 'Education  of  Brooklyn,  New  York,  and  the  Board  deserves 
credit  for  thus  cooperating  with  the  Sanatorium.  Provision  is  now 
made  in  the  larger  cities  for  the  regular  and  systematic  education 
out  of  doors  of  tuberculous  children  in  the  community  at  large  and 
the  success  of  this  movement  is  attested  by  the  fact  that  on  May 
i,  191 3,  there  were  177  open  air  schools  in  the  United  States,  five 
of  these  are  in  Rhode  Island ;  thirty  in  Manhattan ;  twenty  in 
Brooklyn. 

See  also  Jay  Perkins,  M.  D. :  Fresh  Air  Schools — How  .They  Accomplish 
Their  Result   (Journal  of  the  Outdoor  Life,  New  York,  June,   1912). 

Les  EColes  de  Plein  Air,  leur  valeur  prophylatique  dans  la  Lutte  Anti- 
Tuberculose,   "Tuberculosis,"   Berlin,   Nov.,   191 1. 

The  Open-Air  School,  Anna  Garlin  Spencer,  Trans.  Sixth  International 
Congress,  Washington,  1908,  Vol.  2,  p.  612. 

Open  Air  Schools,  Thomas  Wray  Grayson,  M.  D.,  Therapeutic  Gazette, 
Nov.,  1913,  p.  27.    Also  John  V.  Van  Pelt,  Interstate  Med.  Journ.,  April,  1914. 

In  order  to  control  tuberculosis  effectively  we  shall  have  to  make 
more  determined  efforts  to  reach  the  school  children  and  even  those 
of  earlier  years.  Tuberculosis  is  latent  in  thousands  of  children 
in  every  large  city ;  sooner  or  later  it  becomes  manifest  as  vital  resist- 
ance becomes  lowered.  A  recent  view,  prevailing  in  France  and 
Germany,  is  that  all  tuberculous  infections  are  made  in  infancy 
and  childhood,  the  disease  lying  latent,  from  one  cause  or  another, 
until  the  individual  resistance,  weakened  by  successive  colds,  pneu- 
monia, grippe  or  other  infections,  or  exposure  to  reinfection,  finally 
yields  and  tuberculosis  is  actively  established.  Both  laboratory  and 
clinical  experience  point  to  a  much  earlier  primary  infection  than  we 
have  been  accustomed  to  believe  and  hence  too  much  stress  cannot 
be  laid  on  the  importance  of  better  ventilated  schools  and  the  estab- 
lishment of  more  "  fresh-air  schools  "  in  every  city  of  the  country. 
These  should  be  located  near  parks,  if  possible,  or  at  least  have  ex- 
tensive play  grounds.1  They  should  be  conducted  also  for  the  benefit 
of  children  who  may  be  anemic,  nervous,  and  not  necessarily  tubercu- 
lous ;  and  also  for  apparently  healthy  children.  The  best  example  of 
the  outdoor  school  for  normal  children  has  been  opened  at  Bryn  Mawr 
College,  Pennsylvania,  as  the  Phebe  Anna  Thorne  Model  School. 


1  Henry  Barton  Jacobs,  M.  D.,  Journal  of  the  Outdoor  Life,  April,  1908. 

J.  H.  Lowman,  M.  D.,  Trans.  Nat.  Ass.  for  the  Study  and  Prevention  of 
Tuberculosis,  1907. 

The  three  Elizabeth  McCormick  Schools,  in  Chicago,  are  admirable  ex- 
amples of  the  open  air  school. 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    83,    NO.    1,    PL.    34 


GENEVA,   SWITZERLAND 
DELICATE  CHILDREN 


DAY  CAMP    FOR    ANEMIC  AND 


FIG.  2.      FOREST  SCHOOL,   GENEVA,  SWITZERLAND 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL. 


FIG.  1.     OPEN  AIR  SCHOOL   ESTABLISHED  BY  THE  CIVIC  CLUB,   PITTSBURGH,   PENNA.     STUDY 

HOUR;   WARM   WEATHER 


FIG.  2.     OPEN  AIR   SCHOOL   ESTABLISHED  BY  THE  CIVIC  CLUB,   PITTSBURGH.     STUDY 
HOUR:   COLD  WEATHER 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 

i. '•':•■' 


VOL.    63,    NO.     1,    PL.    36 


OPEN   AIR   SCHOOL    ESTABLISHED   BY  THE   CIVIC  CLUB,    FITTSBURGH,  PENNA.      RESTING   HOUR 


SMITHSONIAN     MISCELLANEOUS    COLLECTIONS 


VOL.    83,    NO.    1,    PL. 


FIG.   1.      FRESH  AIR  SCHOOL  ESTABLISHED  BY  THE  CIVIC  CLUB,  PITTSBURGH  PENNA 


FIG.  2.     OPEN  AIR  CLASS  FOR  ANEMIC  CHILDREN  AT  PUBLIC  SCHOOL  NO.  21,  NEW  YORK  CITY 
Courtesy  of  Dr.   J.  W.    Brannan 


a.  tr 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  IO/ 

Other  private  schools  are  advertising  open  air  classrooms,  e.  g.,  the 
Horace  Mann  School,  the  Packer  Institute  of  Brooklyn  and  the 
Brooklyn  High  School. 

All  measures  to  preserve  the  purity  of  air  and  its  freedom  from 
dust  should  be  rigidly  enforced  in  schools.  Bad  ventilation  is  the  rule 
except  in  the  most  modern  school  buildings.  After  two  hours  the  air 
is  depressing  and  carbonic  acid  is  usually  found  in  excess.  The 
problem  of  how  to  deal  with  dust  is  a  difficult  one  in  schools,  owing 
to  the  expense  of  really  efficient  methods.  The  floors  should  not 
have  open  crevices  and  dry  sweeping  should  not  be  allowed.  Sweep- 
ing with  wet  saw  dust  is  probably  the  most  effective,  and  at  the 
end  of  each  term  a  thorough  bacteriological  dust  disinfection  should 
be  carried  out  by  the  Department  of  Health.  Dr.  J.  H.  Lowman, 
of  Cleveland,  who  has  instituted  great  reforms  in  the  hygiene  of 
the  schools  of  that  city,  recommends  not  formaldehyde,  but  that  the 
walls  should  be  cleaned  or  painted,  the  furniture  washed  and  the 
floors  treated  with  dilute  solutions  of  chloride  of  lime. 

We  recognize  tuberculosis  to  be  one  of  the  greatest  dangers  to 
school  children,  for  at  the  tenth  year  the  Prussian  statistics  show 
that  out  of  100  boys  who  die,  9.26  die  of  tuberculosis,  and  out  of 
100  girls,  12.02  die  of  tuberculosis  ;  hence  the  importance  of  all  hygi- 
enic safeguards  against  this  malady. 

Tracheo-bronchial  tuberculosis  and  tuberculosis  of  the  lymphatic 
system  are  the  forms  most  commonly  encountered  and  strict  medical 
inspection  will  reveal  large  numbers  of  children  for  whom  fresh  air 
schools  or  sanatorium  schools  should  be  provided.  In  New  York 
City,  out  of  about  one  hundred  thousand  children  examined  in  1905- 
1906,  dver  one  thousand  were  found  to  have  pulmonary  disease,  and 
in  almost  every  case  it  was  the  first  intimation  to  the  mother  that  her 
child  had  pulmonary  tuberculosis. 

Besides  the  Waldschule  of  Germany  there  are  specially  constructed 
sanatorium  schools  in  Milan,  Italy,  and  vacation  colonies  have  been 
established  near  Geneva,  the  Swiss  Government  supplying  the 
teacher  while  philanthropy  supports  the  schools.  In  Denmark, 
where  the  outing  vacations  are  so  thoroughly  systematized,  the 
teachers  are  supplied  by  the  state.  The  United  States  show  prom- 
ise of  carrying  out  this  enlightened  method  of  dealing  with  the 
tuberculous  problem.  Outdoor  schools  are  conducted  successfully 
in  connection  with  private  camps  for  boys  and  girls.  Many  of  these 
are  in  New  Hampshire  and  Maine,  in  the  vicinity  of  the  Rangeley 
Lakes,  and  in  Oxford  County. 


108  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

IMPORTANCE  OF  VENTILATION 

The  first  desideratum  in  tuberculo-therapy  and  in  the  prevention 
of  tuberculosis  is  abundant  and  free  ventilation.  The  dwelling,  the 
bedroom,  the  workshop,  the  office,  the  church,  the  schoolroom,  the 
theatre,  the  modern  subway  are  one  and  all  dangerous  in  proportion, 
as  their  atmosphere  is  composed  of  dead  or  rebreathed  air.  Not 
only  is  tuberculosis  favored  by  unhygienic  surroundings  and  vitiated 
atmosphere  in  particular,  but  no  other  agent,  not  excepting  alcohol 
and  bad  food,  so  surely  undermines  the  constitution  and  renders 
it  unable  to  resist  disease.  Air  that  has  once  been  breathed,  ought 
not  to  be  breathed  again.  Out  of  doors  the  danger  is  minimized; 
indoors  we  usually  breathe  and  rebreathe  the  contained  air  again 
and  again.  To  some  extent,  of  course,  this  cannot  be  avoided,  but 
we  should  endeavor  to  reduce  it  to  a  minimum.  This  subject  has 
been  recently  investigated  by  Dr.  Thomas  R.  Crowder,  who  studied 
by  ingenious  methods  the  effect  of  such  factors  as  change  of  posi- 
tion, body  motion,  different  types  of  breathing  and  different  tempera- 
tures and,  in  addition,  has  determined  the  conditions  that  obtain  on 
the  sleeping  porch  and  in  the  open  air.  Nasal  breathing  was  the 
type  examined,  since  in  mouth  breathing  there  is,  under  favorable 
circumstances,  little  reinspiration.1 

The  conclusions  that  may  fairly  be  drawn  from  Crowder's  work  are 
that  (1)  a  person  remaining  quiet  and  indoors  will  immediately  rebreathe 
from  1  to  2  per  cent  of  his  own  expired  air;  (2)  when  lying  in  bed  the 
percentage  is  higher,  rising  to  from  4  to  10  per  cent,  depending  on  the  position 
assumed  while  sleeping.  "  Nor  does  sleeping  in  the  open  insure  pure  air 
for  breathing.  The  same  influences  here  produce  the  same  relative  results 
that  they  do  inside.  When  one  buries  his  head  between  pillow  and  bed  clothes 
for  the  sake  of  warmth,  reinspiration  is  inevitable,  and  it  is  not  necessarily 
small  in  amount."  In  addition,  it  must  be  noted  that  at  each  inspiration  we 
reinhale  not  only  some  of  the  air  just  exhaled,  but  also  the  air  contained  in 
the  nose  and  larger  bronchi — the  so-called  "  dead-space "  air.  This  may 
amount  to  one-third  of  the  whole  volume  in  quiet  inspiration  and  not  less 
than   one-tenth  in   deep  breathing. 

The  significance  of  this  study  in  connection  with  questions  of  ventilation 
is  obvious.  Since  even  under  the  most  favorable  conditions  we  cannot  avoid 
drawing  back  into  the  lungs  some  of  the  air  that  has  just  passed  out  of  them, 
not  much  importance  can  be  attached  to  the  slight  variations  in  carbon 
dioxide  content  which  occur  in  the  air  of  rooms. 


1  The  Reinspiration  of  Expired  Air.  Archives  of  Internal  Medicine,  Chi- 
cago, October,' 1913,  p.  1936.  Journ.  Amer.  Med.  Ass.,  Editorial,  Nov.  29,  1913, 
p.  1986. 


CO    3 

5    „ 


NO.    I  AIR    AND    TUBERCULOSIS HINSDALE  IOO, 

OPEN   AIR  CHAPELS  AND  THEATRES 

It  is  remarkable  how  inconsistent  we  all  are  in  matters  of  hygiene. 
Medical  men  are  often  among  the  worst  offenders.  Their  offices 
are  commonly  stuffy,  their  conventions  and  social  gatherings  are 
often  held  in  inadequate  halls  in  which  vitiated  air,  sometimes  reek- 
ing with  smoke,  is  perfectly  abominable. 

If    to    do    were   as    easy   as    to   know    what    'twere    well    to    do 
Then  chapels  had  been  churches  and  poor  men's  cottages  princes' 
palaces. 

We  cannot  go  back  to  the  time  of  the  Druids  or  worship  in 
groves  after  the  manner  of  the  Greeks,  but  it  seems  fitting  here  to 
call  attention  to  one  chapel  that  has  been  specially  constructed  for 
out-of-door  worship  and  that  is  destined  to  be  a  model  for  many  a 
sanatorium  at  least.  This  has  been  constructed  for  the  famous 
King  Edward  VII  Sanatorium  near  Midhurst,  in  Sussex,  England. 
The  accompanying  illustration  of  this  unique  chapel  marks  a  step  in 
advance  in  sanatorium  construction.  It  is  in  the  Moorish  style, 
shaped  like  a  broad  letter  V.  The  double  rows  of  columns  of  the 
cloister  are  on  the  southerly  side,  the  pulpit  and  chancel  are  in  the 
apex  and  the  northerly  sides  forming  the  inner  walls  are  provided 
with  arched  apertures  so  that  the  patients  may  sit  absolutely  in  the 
open  air  but  with  sufficient  protection  from  the  weather  at  all  seasons. 
In  fair  weather  services  are  held  under  the  sky  in  the  open  space 
in  front  of  the  building  between  its  extended  arms.  The  illustra- 
tion shows  this  very  beautifully. 

Open  air  theatres  were  built  by  the  Greeks  and  Romans  and  the 
remains  of  these  structures  are  among  the  most  interesting  of  ancient 
ruins.  In  Europe  the  Passion  Play  at  Bayreuth  is  enacted  wholly  out 
of  doors,  but  is  entirely  apart  from  our  subject  except  so  far  as  it 
demonstrates  the  possibilities  of  out-of-door  representation.  The 
low  theatre  and  concert  hall  are  invariably  hot  and  stuffy  and  un- 
doubtedly foster  tuberculosis  by  inadequate  ventilation.  It  would  be 
better  if  we  could  have  some  theatres  or  assembly  halls  with  per- 
fectly free  circulation  of  air. 

The  Groton  School  in  Massachusetts  has  lately  undertaken  to  build 
an  outdoor  gymnasium,  so  that  the  boys  shall  have  the  advantage  of 
the  open  air  rather  than  in  an  enclosed  building.  This  is  the  first 
school  we  know  of  to  adopt  this  admirable  plan. 

VENTILATION  OF  DWELLINGS 

Ordinary  dwellings  are  terribly  deficient  as  regards  ventilation. 
The  country  dwellings  of  the  poor  are  strangely  defective  in  this 


IIO  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

respect.  It  has  been  said  that  the  reason  why  the  air  in  rural  dis- 
tricts is  so  pure  is  that  the  poor  country  people  have  all  the  bad  air 
shut  up  in  their  houses.  There  is  a  great  deal  of  truth  in  this. 
Doctors  are  constantly  struggling  with  the  strange  aversion  that 
the  rural  population  has  regarding  sufficient  air  in  the  bedrooms. 
As  soon  as  night  falls  the  windows  and  doors  are  tightly  closed  and 
the  kerosene  lamp  adds  to  the  pollution  of  the  air.  It  is  a  common 
experience  to  find  the  doors  and  windows  kept  closely  shut  owing  to 
the  deeply  rooted  fear  of  catching  cold.  In  European  countries  the 
windows  of  many  of  the  older  dwellings  were  originally  intended  for 
light  and  not  for  air,  and  are  merely  panes  of  glass  built  into  the  wall 
and  not  intended  to  be  opened.  Others  are  so  badly  constructed  that 
the  upper  sash  cannot  be  lowered  and  the  lower  sash  is  scarcely  ever 
raised  more  than  a  few  inches. 

The  children  in  many  country  cottages  instead  of  being  rosy  and 
robust,  as  they  should  be  with  healthy  surroundings,  are  frequently 
pale  and  bloodless  on  account  of  this  bad  air.  This  deficient  venti- 
lation of  country  houses  and  the  bad  food  so  common,  where  milk 
and  eggs  ought  to  be  so  plentiful  and  good,  conspire  to  give  to  some 
country  populations  a  bad  start  in  the  earlier  years.  No  better  ex- 
ample can  be  cited  than  that  of  the  "  poor  whites  "  of  the  Southern 
United  States.  Indolence,  ignorance,  general  helplessness  and 
inertia  are  their  characteristics.  Their  children  are  pale  and  gaunt, 
and  their  living  quarters  are  horrible  beyond  description.  It  is  a 
wonder  the  death  rate  among  them  is  not  greater  than  it  is.1 

It  seems  very  strange,  but  it  is  a  fact,  that  about  seventy  years 
ago  a  proposition  was  made  to  use  the  Mammoth  Cave  in  Ken- 
tucky as  a  winter  resort  for  invalids.  Sixteen  consumptives  were 
sent  there  to  gain  the  reputed  benefit  from  the  equable  temperature 
and  asserted  purity  of  the  air  in  that  cavern.  Five  of  these  patients 
died  and  the  others  were  injured  as  a  result  of  the  darkness  and 
dampness  combined.  That  such  an  irrational  and  cruel  experiment 
should  have  been  tried  seems  incomprehensible  at  the  present  day.2 


1  The  death  rate  from  pulmonary  tuberculosis  for  Virginia  during  the  year 
ending  June  30,  1913.  was  for  whites  98.4,  and  for  colored  256  per  100,000. 
The  state  rate  was  estimated  at  148. 

2  See  Croghan:  The  Mammoth  Cave  as  a  Winter  Resort  for  Invalids  (Bos- 
ton Medical  and  Surgical  Journal,  1843,  Vol.  28,  p.  188). 

Daniel  Drake,  M.  D. :  Western  Journal  of  Medicine  and  Surgery,  Louis- 
ville, Kentucky,   1843,  Vol.  7,  p.  78. 


SMITHSONIAN      MISCELLANEOUS   COLLECTIONS 


NO.     1  .    FL.    42 


OPEN   AIR    DINING   HALL.      DR.  WALTHER'S  SANATORIUM,   NORDRACH-COLONIE,    BLACK 
FOREST,   GERMANY 


LAWN   CUTTING.     GRADUATED  LABOR   IN    PULMONARY  TUBERCULOSIS.     SANATORIUM   OF  THE 
BROMPTON    HOSPITAL,   FRIMLEY,    ENGLAND 


o   ° 


5  o 


NO.    I  AIR  AND  TUBERCULOSIS — HINSDALE  111 

CHAPTER  VIII.     EXERCISE  IN  TUBERCULOSIS;    GRADUATED 

LABOR 

The  Nordrach  system  of  treatment  of  pulmonary  tuberculosis  car- 
ried out  by  Or.  Walther  and  that  of  his  predecessor,  Dr.  Brehmer, 
at  Goebersdorf,  in  Silesia,  involves  much  exercise  in  addition  to 
fresh  air  and  alimentation;  the  Dettweiler  system  enjoins  rest  in 
the  open  air  with  superalimentation.  McLean's  dictum  is:  "  If  the 
phthisical  patient  would  live,  he  must  work  for  it."  '  Probably  this 
advice  should  not  be  taken  too  literally,  at  least  by  every  tuberculous 
patient ;  but  graduated  physical  exercise  has  a  very  important  and 
useful  place  in  the  treatment  of  most  patients.  Brehmer  advocated 
hill-climbing-,  while  Walther  advises  graduated  walking  exercises, 
in  some  cases  to  the  extent  of  walking  twenty  miles  a  day.  Whether 
one  practices  walking,  or  hill-climbing  or  graduated  labor,  we  cannot 
dissociate  from  these  measures  the  effect  of  atmospheric  air,  in  its 
various  qualities,  upon  the  lungs  and  the  accompanying  stimulation  of 
the  pulmonary  and  general  circulation.  Two  recent  papers  by  London 
practitioners  are  full  of  such  suggestive  thoughts  on  this  subject  that 
we  call  special  attention  to  them.  They  are  considered  by  some  as 
marking  an  epoch  in  the  treatment  of  pulmonary  tuberculosis. 

At  a  meeting  of  the  Medical  Society  of  London,  January  13,  1908, 
Dr.  Marcus  S.  Paterson,  the  Medical  Superintendent  of  the  Bromp- 
ton  Hospital  Sanatorium,  at  Frimley,  read  a  paper  on  "  Graduated 
Labor  in  Pulmonary  Tuberculosis  "  which  was  supplemented  by  an- 
other on  the  "  Effect  of  Exercise  on  the  Opsonic  Index  of  Patients 
Suffering  from  Pulmonary  Tuberculosis,"  by  Dr.  A.  C.  Inman,  Super- 
intendent of  the  Laboratories,  Brompton  Hospital." 

The  patients  for  whom  Paterson  instituted  graduated  labor  were 
selected  cases  sent  from  the  Brompton  Hospital  in  London  to  its 
Sanatorium  at  Frimley,  at  an  elevation  of  380  feet  in  the  country. 

He  was  induced  to  carry  out  this  plan  of  treatment  after  seeing 
tuberculous  patients  who  did  well  while  working  under  unfavorable 
surroundings  ;  but  he  believed  that  under  careful  regulation  of  labor 
and  with  very  careful  observation  of  the  temperature  records,  he 
might  safely  proceed.  The  exercises  adopted  involved  all  the 
muscles  of  the  trunk  and  extremities  and  this  was  thought  to  be 
better  than  walking  exercises  in  which  the  lower  limbs  were  chiefly 
employed.    The  use  of  the  upper  limbs  seemed  more  likely  to  favor 


'McLean:    Personal   Observation   in   Phthisis   Pulmonalis    (Journal  Amer. 
Med.   Ass.,  February,  1898). 
8  The  Lancet.  January  25,  1908. 


112  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

the  expansion  of  the  lungs.  It  was  not  forgotten  that  the  common 
objections  to  this  plan  of  treatment  are,  (i)  that  the  disease  would 
become  active  again  under  the  strain;  and  (2)  that  the  exertion 
would  tend  to  produce  hemoptysis.  Considerable  tact  and  personal 
influence  must  have  been  exerted  to  get  the  patients  to  carry  out  a 
plan  which  involved  increasing  labor  and  measures  that  are  generally 
considered  positively  harmful. 

The  first  exercise  ordered  was  walking,  the  distance  being  gradu- 
ally increased  up  to  ten  miles  a  day.  When  a  patient  had  reached 
this  stage  he  was  given  a  basket  in  which  to  carry  mould  for  spread- 
ing on  the  lawns.  No  case  of  hemoptysis  or  of  pyrexia  occurred 
among  these  patients.  When  they  had  been  on  this  grade  with  noth- 
ing but  beneficial  results  for  from  three  weeks  to  a  month,  they 
were  given  boys'  spades  with  which  to  dig  for  five  minutes  followed 
by  an  interval  of  five  minutes  for  a  rest.  After  a  few  weeks,  several 
of  the  patients  on  this  work,  who  were  doing  well,  were  allowed  to 
work  as  hard  as  possible  with  their  small  spades  without  any  inter- 
vals for  rest.  As  they  had  all  improved  on  this  labor  larger  shovels 
were  obtained,  and  it  was  found  that  the  patients  were  able  to  use 
them  without  the  occurrence  of  hemoptysis  or  a  rise  of  temperature. 
About  this  time  many  of  the  patients  were  feeling  so  well  that  it  be- 
came necessary  to  restrain  them  from  doing  too  much. 

These  results  in  a  few  cases  creates  a  most  favorable  sentiment 
among  the  other  patients  so  that  the  system  was  extended  generally, 
with  great  care  and  minute  supervision.  Harder  work  was  pre- 
scribed for  patients  who  could  be  trusted  even  to  the  use  of  spades, 
shovels  and  five  pound  pick-axes.  The  patients  all  expressed  the 
opinion  that  the  work  did  them  good  and  that  the  harder  they 
worked  the  better  they  felt.  Many  patients  have  written  to  Dr. 
Paterson  to  say  that  they  date  their  improvement  from  the  com- 
mencement of  the  labor,  and  that  they  think  the  hardest  work  did 
them  the  most  good.  It  certainly  speaks  well  for  the  strict  supervision 
of  these  patients  that  no  accidents  occurred  of  a  serious  nature, 
though  several  developed  fever  and,  subsequently,  pleurisy.  One 
patient  was  laid  up  for  two  months  and  was  much  worse  at  the  end  of 
that  time,  though  eventually  he  did  well  and  returned  to  work,  though 
the  extent  of  his  disease  was  increased  through  overexertion. 

The  suitability  of  cases  for  graduated  labor  rests  on  a  very  careful 
physical  examination,  importance  being  laid  on  the  general  muscular 
and  physical  development.  Marked  wasting  and  poor  development 
is,  naturally,  a  bar  to  this  method  of  treatment.    The  resisting  power 


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NO.    I  AIR    AND   TUBERCULOSIS       HINSDALE  113 

of  a  patient  with  a  very  limited  lesion  is  an  unknown  quantity  and 
has  to  be  determined,  whereas  a  patient  with  a  lesion  involving  four 
lobes  may  remain  at  work  for  some  time  and  exhibit  a  good  initial 
resisting  power. 

Dr.  Paterson  lays  very  great  stress  on  the  temperature  taken  in  the 
mouth.  If  this  is  or  has  been  99  °  F.  or  over  during  the  week 
preceding  admission  to  the  sanatorium,  the  patient  is  put  to  bed 
after  the  journey.  So  long  as  the  temperature  remains  at  99°  F. 
in  the  case  of  men  or  99.60  F.  in  the  case  of  women,  the  patient 
is  not  allowed  up  for  any  purpose.  So  long  as  the  temperature  is 
unaffected  by  exertion  the  patient  is  gradually  allowed  up  for  longer 
and  longer  periods.  Patients  with  apparently  limited  disease,  but 
who  are  in  poor  general  condition  and  without  fever,  are  allowed 
to  be  up  all  day,  but  are  not  permitted  to  take  further  exercise 
than  is  entailed  by  walking  to  and  from  the  dining  hall  for  their 
meals.  The  remainder  of  the  day  is  spent  in  resting.  As  their  con- 
dition improves  they  are  allowed  to  walk  half  a  mile  a  day,  and  so 
on,  until  a  distance  of  six  miles  a  day  is  reached.  The  rate  of  in- 
crease in  the  amount  of  exercise  depends  upon  such  factors  as  the 
patient's  disposition,  weight  and  appetite. 
The  grades  of  work  are  briefly  as  follows  : 
(A  1)   Walking  from  one-half  to  ten  miles  daily. 

(1)  Carrying  baskets  of  mould  or  other  material. 

(2)  Using  a  small  shovel. 

(3)  Using  a  large  shovel. 

(4)  Using  a  five-pound  pick-axe. 

(5)  Using  a  pick-axe  for  six  hours  a  day. 

Patients  in  grades  1,  2,  3,  and  4,  work  four  hours  a  day. 

The  basket  work  in  which  about  eight  pounds  of  earth  are  carried 
is  considered  the  most  important  and,  as  a  rule,  patients  spend  far 
more  time  in  this  work  than  in  any  other.  It  brings  into  use  all  the 
muscles. 

Work  has  a  wholesome  effect  on  the  mind.  If  the  patient  is  at 
first  sullen  and  apathetic,  the  improvement  in  physical  condition 
quickly  begets  a  lively  and  cheerful  mental  attitude,  and  one  that 
seeks  work  rather  than  to  shirk  it. 

During  1905  and  1906  the  number  of  patients  discharged  from 
this  sanatorium  was  164,  and  they  all  returned  to  their  previous 
occupations,  whatever  they  happened  to  be,  and  not  to  light,  outdoor 
work.  They  were  fitted  by  the  line  of  treatment  which  we  have  de- 
scribed for  effective  wage  earning. 


I  14  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

We  have  dwelt  quite  fully  on  this  innovation  in  tuberculo-therapy 
because  it  gives  promise  of  good,  practical  results  and,  further,  be- 
cause it  is  so  radically  different  from  the  prevailing  methods  adopted 
in  most  sanatoria.  But,  the  most  interesting  feature  is  the  explana- 
tion which  is  offered  to  account  for  the  benefits  which  has  accrued. 
This  explanation  is  set  forth  in  an  elaborate  study  made  by  A.  C. 
Inman,  M.  B.,  the  superintendent  of  the  laboratories  of  the  Bromp- 
ton  Hospital,  on  the  "Effect  of  Exercise  on  the  Opsonic  Index  of 
Patients  Suffering  from  Pulmonary  Tuberculosis."1 

This  study  of  Inman's  was  prompted  and  made  possible  by  the 
brilliant  work  of  Sir  Almroth  Wright.  Wright  showed  in  his  Har- 
veian  Lecture  in  New  York,  that  there  are  three  great  agencies  by 
which  immunizing  responses  can  be  evoked  in  the  organism: 

(1)  By  the  inoculation  of  bacterial  vaccines. 

(2)  By  artificially  induced  auto-inoculations. 

(3)  By  spontaneous  auto-inoculations. 

Wright  had  previously  elucidated  the  subject  of  vaccine  therapy 
by  constructing  curves  from  the  opsonic  indices  of  patients  vacci- 
nated against  their  infection  and  in  this  manner  traced  a  definite 
train  of  events  which  follow  upon  a  single  inoculation.  The  succes- 
sive phases  were  termed  the  negative  phase,  the  positive  phase  and 
the  phase  of  maintained  high  level.  Freeman,  working  in  Wright's 
laboratory,  then  took  up  the  subject  of  massage  in  its  effect  on  gono- 
coccal joints  showing  that  "Auto-inoculations  follow  upon  all  active 
and  passive  movements  which  affect  a  focus  of  infection  and  upon 
all  vascular  changes  which  activate  the  lymph-stream  in  such  a 
focus." 

Wright's  dictum  was  that  "  where  in  association  with  a  bacterial 
invasion  of  the  organism  bacteria  or  bacterial  products  pass  into 
the  general  lymph,  and  blood-stream,  intoxication  effects  and  im- 
munizing responses,  similar  to  those  which  follow  upon  the  inocula- 
tion of  bacterial  vaccines,  must  inevitably  supervene."  It  is  a  per- 
fectly logical  conclusion,  then,  that  nature  cures  bacterial  infections 
through  such  auto-inoculations.  Inman  set  himself  to  find  out  what 
the  body  is  doing  of  itself  and  what  value  extraneous  circumstances, 
such  as  physical  exercise,  have  in  aiding  these  attempts  on  the  part 
of  the  body.  Inman's  work  was  conducted  on  a  carefully  planned 
technique,  controlled  and  checked  at  all  points,  using  forty-three 
patients  in  the  sanatorium  treated  by  the  System  of  Graduated  Labor. 

Inman  found  that  in  41  out  of  43  cases  the  opsonic  index  was  at 


1  Read  before  the  Medical  Society  of  London,  January  13,  1908. 


" 


V. v 

A'  4'*- 

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NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  1 15 

some  time  of  the  day  well  above  the  normal,  and  what  is  of  even 
more  importance,  in  no  case  did  the  exercise,  even  though  severe, 
lower  the  index  below  the  normal  line — that  is,  the  auto-inoculation 
was  never  so  great  as  to  produce  a  negative  phase  and,  therefore, 
never  in  excess. 

It  was  observed  during  these  investigations  that  in  some  bloods  examined, 
tuberculo-agglutinins  appeared  in  association  with  the  immune  tuberculo- 
opsonins.  This  must  be  taken  as  another  evidence  of  an  immunizing  response 
on  the  part  of  the  organism.  When  the  difficulties  of  such  a  method  of  treat- 
ment and  the  danger  of  the  weapon  employed  are  taken  into  consideration 
it  will  be  readily  understood  that  every  now  and  then,  in  spite  of  the  most 
careful  supervision,  an  excessive  auto-inoculation  must  take  place.  Such  an 
over-dose  is  readily  recognized  clinically.  A  patient  doing  well  on  the 
grade  of  work  prescribed  for  him  and  with  no  abnormality  of  temperature 
suddenly  complains  of  feeling  tired,  of  loss  of  appetite  and  of  headache; 
and  the  temperature  chart  registers  an .  elevation  to  99  °  or  ioo°  F.  These 
are  precisely  the  symptoms  which  are  found  during  the  negative  phase  after 
an  excessive  dose  of  bacterial  vaccine. 

Thus  we  have  a  new  scientific  test  by  which  the  effect  of  physical 
exercise  on  the  blood  of  patients  has  been  traced.    As  Inman  says  : 

The  opsonic  index  has  shown  that  the  exercise  has  supplied  the  stimulus 
needed  to  induce  artificial  auto-inoculation,  and  that  this  systematic  gradua- 
tion has  regulated  this  in  point  of  time  and  amount.  This  co-operation  with 
the  natural  efforts  of  the  blood  has  enabled  Dr.  Paterson  to  send  his  patients 
back  to  their  accustomed  work,  however  hard  it  may  be.  But  the  investigation 
has  done  more  than  explain  a  successful  mode  of  treatment.  Dr.  Paterson 
agrees  with  me  that  with  the  aid  of  the  opsonic  index  he  can  regulate  the 
stimulus  with  scientific  accuracy  and  obtain  his  results  more  certainly  and 
more  rapidly.  This,  of  course,  involves  work  in  the  laboratory.  But  it  also 
means  a  more  rapid  and  a  more  certain  discharge  of  the  patient  which  is  the 
main  object  of  the  sanatorium. 

Fresh  air,  exercise,  and  proper  food  seem  then  to  constitute  the 
foundation  of  successful  treatment  of  tuberculosis.  The  improve- 
ment of  the  general  condition  of  the  patient  and  life  in  the  open  air 
evidently  needs  to  be  supplemented  by  certain  exercise  so  as  to  pro- 
duce a  series  of  auto-inoculations  and  probably  the  best  method  yet 
devised  is.  by  the  system  of  graduated  labor  just  described. 

All  sorts  of  exercises  such  as  horseback  riding,  golfing,  light 
dumb-bell  exercises  and  other  calisthenics  have  been  practiced  for 
many  years  in  treating  tuberculosis ;  walking  exercises  have  been  the 
feature  of  some  of  the  German  sanatoria  referred  to ;  patients  sent 
to  the  western  states  and  territories  almost  invariably  practiced  out- 
door exercises,  some  with  great  harm  and  some  with  benefit. 
Neither  physician  nor  patient  in  most  instances  regulated  these  exer- 
1 1 


Il6  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

cises  intelligently,  but  groped  in  the  dark,  never  dreaming  of  the 
underlying  principles  as  explained  by  laboratory  studies  of  Sir  Alm- 
roth  Wright,  Paterson,  Inman,  and  others.  We  trust  that  further 
studies  and  the  application  of  the  same  method  in  Europe  and 
America  will  fix  the  value  of  exercise  in  tuberculosis. 

A  somewhat  similar  system  of  graduated  labor  has  been  adopted 
in  the  King  Edward  VII  Sanatorium  near  Midhurst,  England. 
Light  work  in  the  gardens  and  grounds  is  prescribed  in  lieu  of  some 
of  the  walking  exercise  and  forms  part  of  the  regular  treatment. 
Practical  gardening  in  the  grounds  and  flower  beds  is  utilized.  The 
lightest  labor  consists  of  weeding,  hoeing  and  edging  paths  and  bor- 
ders, gathering  seeds,  plucking  dead  flowers,  pruning,  etc.  Some- 
what harder  exercise  consists  in  wheeling  soil  to  the  lawns  and 
spreading  it,  clearing  ground  of  stones  and  taking  them  away  in 
barrows,  and  in  leveling  new  ground  after  being  broken  up.  The 
heaviest  work  is  that  of  digging  and  trenching  unbroken  ground, 
moving,  rolling,  etc.  Paths  through  the  pine  woods  have  also  been 
constructed.  In  this  particular  work  the  breaking  up  of  the  ground 
with  picks  and  clearing  away  the  roots  from  neighboring  trees  was 
allotted  to  the  first  division  of  patients.  The  second  division  cleared 
away  the  broken  ground  and  roughly  leveled  it.  The  third  division 
finished  the  leveling  of  the  paths  with  rakes  and  tidied  up  the  edges.1 

Free  patients  at  the  King's  Sanatorium  have  made  a  cinder  tennis 
court ;  they  have  cut  down  and  sawed  fire  wood ;  they  have  an  open 
air  carpenter  shop  and  an  instructor  in  carpentry,  who  is  himself  a 
patient ;  they  care  for  the  poultry  and  make  the  runs  for  the  fowls. 
In  this  way  patients  are  constantly  occupied. 

Although  the  system  of  graduated  exercises,  or  labor,  adopted 
at  the  sanatoria  referred  to,  has  attracted  wide  notice  and  its  princi- 
ples were  there  first  placed  on  a  highly  scientific  basis,  there  were 
previous  attempts  to  do  this  in  an  intelligent  and  rational  manner. 
Sir  Robert  Philip,  at  Edinburgh,  over  twenty  years  ago,  before  the 
bacteriology  of  tuberculosis  had  been  so  well  developed,  prescribed 
practically  the  same  thing  as  a  therapeutic  measure  of  definite  dos- 
age. He  had  had  classes  of  selected  patients  who  came  at  fixed 
hours  to  take  regular  training  with  regard  to  posture  and  healthy 
respiratory  movement.  More  especially  the  young  were  taught  the 
value  of  a  healthy  form  of  chest,  the  principles  of  nose-breathing 
and  full  diaphragmatic  movement.  "  In  addition  to  this,  meas- 
ured walks  of  varying  amount  and  gradient  were  prescribed  exactly 


1  Noel  Dean  Bardswell,  Tuberculosis,   Berlin,   May,   ic 


NO.     I  AIR    AND  TUBERCULOSIS— HINSDALE  I  '7 

as  we  prescribe  medicines.  Thus  we  had  walks  radiating  from  the 
dispensary  round  the  meadows,  walks  over  the  Bruntsfield  Links 
and  walks  in  various  directions  on  the  slopes  of  Arthur's  Seat.  The 
patients  reported,  at  successive  visits,  their  experience  in  carrying  out 
such  instructions  and  notes  were  made  of  the  effects  produced." 
Here  we  see  the  germ  of  the  class  method  so  well  developed  and 
practiced  bv  Pratt,  of  Boston,  although  he  is  an  apostle  of  rest 
rather  than  labor. 

The  results  in  Philip's  hands  were  eminently  satisfactory.  'The 
patients  did  remarkably  well  and  no  accident  was  traced  to  the 
adoption  of  active  movement  instead  of  rest.  The  experience  led  to 
a  change  in  my  outlook  in  relation  to  the  meaning  of  treatment  in 
tuberculosis."  Philip  came  to  the  conclusion  that  by  the  establish- 
ment of  hospitals  or  sanatoria  for  patients  in  the  earlier  stages  of 
tuberculosis  "  we  might  hope  to  achieve  permanent  cures  to  a  degree 
not  dreamt  of,  by  elaboration  of  the  principle  of  regulated  exercises 
and  graded  activity  of  all  kinds."  These  conclusions  were  justified 
by  the  results  obtained  "  in  the  home  treatment  undertaken  for  so 
many  years  at  the  Victoria  Dispensary  and  in  the  systematized 
regime  of  work  at  the  Royal  Victoria  Hospital  and  the  recently 
opened  Farm  Colony." 

Sir  Robert  Philip  lays  great  stress  on  the  well-known  fact  that 
there  is  a  progressive  intoxication  in  tuberculosis  and  the  toxins  pro- 
duced by  the  tubercle  bacillus  appear  to  exert  their  vicious  influence 
particularly  on  the  neuromuscular  apparatus.  The  toxin  is  especially 
a  muscle  poison.1  There  is  a  visible  and  palpable  progressive  wasting 
of  the  muscles,  both  of  the  trunk  and  the  extremities,  with  advancing 
rlaccidity  and  increased  myotatic  irritability.  It  is  an  expression  of 
malnutrition,  a  muscular  dystrophy  dependent  on  intoxication.  The 
obvious  conclusion  is  that  by  the  institution  of  natural  movements 
the  physiologic  cure  of  "  recreation  "  is  assisted  and  health  gradu- 
ally returns. 

Sir  Robert's  scheme  of  physical  treatment  at  the  Royal  Victoria 
Hospital  is  worthy  of  mention.  On  admission  each  patient  is  placed 
at  complete  rest.  During  this  stage,  in  addition  to  minute  examina- 
tion of  every  organ,  the  patients  general  condition  is  carefully  ob- 
served. According  to  the  estimate  which  is  made  the  length  of  the 
resting  period  is  fixed.  Thereafter,  in  the  absence  of  counter-indica- 
tion, the  patient  is  gradually  advanced  through  the  other  stages. 


1 R.    W.    Philip,    Trans.    International    Med.    Congress,    Washington,    1887, 
Vol.  1,  p.  205. 


Il8  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

The  dose  of  exercise  is  increased  or  diminished  as  the  temperature 
chart,  pulse  rate  and  other  indications  suggest.  A  colored  badge  is 
given  to  the  patient  to  denote  the  stage  he  has  reached. 

I.  Resting  Stage,  as  noted  above.     (White  Badge.) 

IT.  Stage  of  Regulated  Exercises.  (Yellow  Badge.)  This  includes  (1) 
walking  %  to  5  miles;  (a)  on  the  level;  (b)  on  sloping  ground.  (2)  Various 
respiratory  exercises  once  or  twice  a  day.  (3)  Other  forms  of  movements 
to  improve  carriage  of  shoulders,  head,  chest,  etc. 

III.  Stage  of  Regulated  Work.     (Pale  Blue  Badge.) 

IIIA.  Picking  up  papers,  leaves  and  other  light  rubbish  on  the  grounds : 
knitting;  sewing;  drawing. 

MB.  (Green  Badge.)  Emptying  waste  garden  boxes  and  assisting  to  carry 
away  rubbish.  Carrying  light  baskets  for  various  garden  purposes.  Light 
painting  work,  wiping  shelters ;  setting  tables  and  laying  cloth  in  patients' 
dining   room ;    cleaning   silver,   brasses,   taps,    etc. 

IIIC.  (Deep  Blue  Badge.)  Raking,  hoeing;  mowing;  sweeping  leaves ; 
light  wheel-barrow ;  heavier  painting  work ;  sweeping  shelters ;  scrubbing" 
floors ;   cleaning  knives ;    assisting  in   laundry ;   washing   dishes. 

II1D.  (Red  Badge.)  Digging;  sawing;  carrying  heavy  baskets  for  various 
gardening  purposes ;  wheeling  and  drawing  full  wheel-barrow  and  other 
heavy  gardening  work.  Window  cleaning  and  polishing  floors;  sweeping 
and  cleaning  court  yard.  Carpentering;  joinering;  engineering;  attending 
boiler;    errands. 

An  institution  providing  diversified  occupations  has  a  great  advan- 
tage over  one  whose  patients  are  restricted  to  walking  exercises  and 
where  the  women  are  employed  in  kitchen  work  and  the  men  as 
laboratory  orderlies,  assistants  in  the  drug  rooms,  clerks  and  so  on. 
It  is  well  to  vary  the  walking  exercise  with  manual  labor.  Patients 
welcome  it  and  take  a  great  interest  in  the  various  occupations  they, 
are  put  to.  They  acquire  confidence  in  themselves  as  they  see  their 
muscular  tone  improving  and  some  prospect  of  resuming  useful 
occupations. 

With  various  modifications  suggested  by  local  conditions  the  sys- 
tem of  graduated  labor  described  above  is  now  adopted  at  various 
institutions  in  America  ;  in  many  cases,  however,  the  economic  aspect 
of  the  plan  of  treatment  apparently  overshadows  the  therapeutic 
features  ;  probably  the  best  examples  of  the  method  are  at  the  Loomis 
Sanatorium,  New  York,  Otisville  State  Sanatorium,  New  York,  The 
Adirondack  Cottage  Sanitarium,  New  York,  The  North  Reading- 
State  Sanatorium,  Massachusetts,  and  The  Barlow  Sanatorium,  Los 
Angeles,  California.  Dr.  Barlow  has  kindly  sent  me  the  following 
description  of  the  method  he  has  carried  out : 

This  institution  is  semi-charitable  and  receives  cases  in  all  stages. 
You  ask  me  to  send  you  a  statement  of  our  use  of  graduated  labor.    I  will 
give  you  the  facts  as  we  handle  the  matter,  which  is  somewhat  modified  to 


-      mm 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  M'y 

meet  the  needs  of  our  institution.  It  seems  to  me  that  every  institution  must 
modify  this  according  to  the  facilities  at  command.  Our  working  plan  is  as 
follows  : 

All  the  patients  without  any  fever  are  kept  absolutely  quiet  for  the  first 
two  or  three  weeks,  except  that  they  are  allowed  to  go  to  the  dining  room 
for  meals.  If,  during  this  time,  there  is  no  elevation  of  temperature,  no 
marked  acceleration  of  pulse,  and  no  loss  of  weight,  they  are  started  on  exer- 
cise, beginning  with  ten  minutes'  walking  twice  a  day.  If  they  continue  to  do 
well,  gain  weight,  temperature  remains  normal,  and  progress  of  physical  signs 
is  favorable,  then  exercise  is  increased  every  two  weeks.  The  amount  of 
exercise  is  charted  for  each  patient;  one  copy  posted  on  the  bulletin  board, 
and  one  copy  retained  by  the  nurse  in  charge  of  the  order,  to  check  up  the 
allowance  for  each  patient.  Patients  who  have  more  than  ten  minutes'  exer- 
cise twice  a  day  make  their  own  beds  and  keep  their  rooms  in  order,  except 
the  heavy  cleaning.  After  patients  have  reached  an  allowance  of  thirty 
minutes  twice  a  day,  they  are  assigned  to  more  practical  work  about  the 
place  or  grounds.  In  making  these  assignments,  the  patient's  physical  condi- 
tion and  progress,  former,  and  probably  future,  occupation  are  considert-il. 
Most  of  these  assignments  are  changed  each  month,  the  effort  being  to  try  to 
increase  the  work  each  month.  The  work  done  includes  the  setting  of  tables 
in  the  dining  room,  removing  and  washing  dishes,  work  in  the  diet  kitchen, 
looking  after  books  and  pamphlets  in  the  library,  cataloguing  books,  statisti- 
cal work,  stenography  and  typewriting,  carrying  mail,  light  repairs  about 
buildings,  care  of  paths  and  summer-houses,  sprinkling  during  dry  weather, 
and  operating  the  incinerator.  Many  patients  are  assigned  to  flower  beds  of 
their  own,  or  to  doing  light  work  in  caring  for  the  sanatorium  grounds.  In 
carrying  out  this  exercise  or  labor,  careful  watch  is  kept  over  patients,  and 
if  any  elevation  of  temperature,  acceleration  of  pulse,  or  extension  of  physical 
signs  are  observed,  they  are  put  back  to  rest.  The  purposes  that  this  exercise 
and  labor  seem  to  serve  are,  recreation,  stimulating  the  appetite  and  digestion, 
building  up  healthy  tissue,  inducing  healthy  sleep,  and  testing  the  patients 
against  relapses  when  they  resume  their  normal  way  of  living  after  being  dis- 
charged. We  find  that  patients  who  accept  the  occupation  cheerfully  make 
better  progress  mentally  and  physically  than  those  who  resent  being  assigned 
to    duties. 

For  patients  with  an  elevation  of  temperature  99°  or  over,  acceleration  of 
pulse,  either  loss  or  no  gain  in  weight,  or  who  do  not  show  improvement  in 
other  ways,  rest  is  continued,  and  exercise  or  assigned  work  is  deferred. 

At -the  present  time  (December  11,  1913).  there  are  43  patients  in  the 
sanatorium.  Ten  are  in  the  infirmary;  thirty-three  in  open-air  cottages;  of 
the  latter  twenty-seven  are  doing  their  own  work,  and  twenty-five  additional 
assigned  work.  Of  the  six  in  open  air  cottages  not  doing  their  own  work, 
three  are  new  patients  who  have  been  recently  admitted  and  not  under  obser- 
vation  a   sufficient  time   for  report. 

REFERENCES   TO  WORKS  ON   EXERCISE  AND  WORK 

Sir  Robert  W.  Philip:  Rest  and  Movement  in  Tuberculosis  (British  Medi- 
cal Journal,  December  24,  1910). 

Albert  Robin:  How  Consumption  is  Cured  by  Work  (Therapeutic  Gazette, 
December,  1911,  p.  854-865). 


120  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

Lawrason  Brown  and  F.  H.  Heise :  Properly  Regulated  Rest  and  Exercise 
in  Pulmonary  Tuberculosis    (Journal  of  the  Out-Door  Life,  August,   1912). 

J.  W.  Flinn :  Rest  and  Repair  in  Pulmonary  Tuberculosis  (Journ.  Amer. 
Med.  Ass.,  Aug.  16,  1913,  p.  466). 

L.  Teleky :  Choice  of  Occupation  with  Regard  to  Tuberculosis  (Wien. 
klin.  Wochnschr.,  March  13,  1913;  abstr.,  Journal  Amer.  Med.  Ass.,  April  26, 
1913,   P-    1336). 

S.  R.  C.  Halcomb:  Graduated  Labor  in  Pulmonary  Tuberculosis  (Military 
Surgeon,  February,  1913 ;  abstr.,  Journ.  Amer.  Med.  Ass.,  Oct.  26,  1912,  p. 
1564). 

J.  W.  Allan:  Graduated  Labor  at  Bellefield  Sanatorium  (Glasgow  Med. 
Journ.,  January,  1911;  abstr.,  Journ.  Amer.  Med.  Ass.,  Feb.  4,  1911,  p.  384). 

A.  P.  Francine :  Rest,  Exercise  and  Food  in  the  Management  of  Tubercu- 
losis (New  York  Med.  Jour.,  Dec.  31,  1910;  abstr.,  Journ.  Amer.  Med.  Ass., 
Oct.  29,  1910). 

M.  Paterson :  Treatment  of  Pulmonary  Tuberculosis  by  Graduated  Rest 
and  Exercise   (Practitioner,  January,  1913). 

C.  C.  MacCorison  and  N.  B.  Burns :  Method  of  Recording  Exercise  Data 
in  Sanatorium  for  Consumptives  (Boston  Med.  and  Surg.  Journ.,  May  9, 
1912). 

CHAPTER    IX.     ACCESSORIES    FOR    THE    FRESH    AIR    TREAT- 
MENT   OF   TUBERCULOSIS 

It  would  be  impossible  to  carry  out  the  fresh  air  treatment  of 
tuberculosis  without  some  special  facilities  or  accessories.  These 
vary  somewhat  in  accordance  with  the  plan  of  treatment,  whether 
singly  or  collectively ;  or  in  cities,  forests,  or  plains.  Among  these 
accessories  we  include :  (i)  Tents  ;  pavilion  tents.  (2)  Tent  houses  ; 
shacks,  "lean-tos."  (3)  Disused  trolley  cars.  (4)  Balconies  or 
leigeterrasse  for  day  use.  (5)  Day  camps.  (6)  Sleeping  porches 
or  balconies.  (7)  Wooden  pavilions.  (8)  Glass  pavilions.  (9) 
Hospital  roof  wards.  (10)  Detached  Cottages.  (11)  Sleeping 
canopies. 

Tents. — Tents  have  the  advantage  of  low  cost,  portability,  and  the 
fact  that  they  are  adapted  for  almost  any  locality,  whether  in  the 
city,  the  forest,  or  the  plains.  In  the  city  a  tent  for  the  use  of  a 
tuberculous  patient  usually  attracts  too  much  notice  and  unfavorable 
comment  unless  placed  in  a  rural  district.  It  is  possible,  however, 
to  erect  tents  in  the  heart  of  a  great  city,  hundreds  of  feet  above  the 
ground  where  an  abundance  of  pure  air  and  sunlight  are  obtained. 
The  modern  hotel  or  office  building  can  furnish  a  far  better  site,  in 
these  particulars,  than  many  rural  districts.  The  author  is  not  aware 
of  any  extensive  use  of  tall  buildings  for  the  treatment  of  pulmonary 
tuberculosis,  but  it  would  seem  to  be  an  entirely  feasible  proposition. 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  121 

Anyone  who  will  read  the  interesting-  story  by  Van  Tassel  Sutphen 
entitled  "  The  Negative  Pole,"  *  will  find  the  history  of  an  interesting 
case  of  pulmonary  tuberculosis  cured  by  residence  of  eighteen  months 
on  the  top  of  a  modern  "  skyscraper."  The  patient  had  been  advised 
to  remove  to  Arizona,  but  circumstances  made  this  advice  impossible 
to  follow ;  as  an  alternative  measure  he  isolated  himself  almost  en- 
tirely from  the  world  in  the  midst  of  a  metropolis,  and  was  rewarded 
by  a  complete  cure.  The  imaginative  author  of  this  original  story 
assigns  to  the  patient  a  much  more  difficult  role  than  need  be  assumed 
by  anyone  who  may  follow  the  general  line  of  treatment  and  perhaps 
we  may  hear  of  many  who  may  be  encouraged  to  carry  out  the  plan 
suggested. 

In  the  forest  during  the  warmer  season  tents  are  almost  indispensa- 
ble. A  substantial  tent  properly  erected,  protected  with  a  "  fly  "  and 
with  a  surrounding  trench  to  provide  for  excessive  rainfall,  can  be 
made  a  comfortable  and  healthful  habitation  during  a  large  part  of 
the  year. 

The  ventilation  of  tents,  and  their  heating  in  cold  weather,  have 
received  a  great  deal  of  study,  and  as  they  are  perfected  in  these 
respects  their  suitability  for  a  continuous  residence  throughout  the 
year  has  been  proved.  Tents  can  be  made  storm  proof  and  almost 
as  comfortable  in  stormy  weather  as  an  ordinary  building.  On 
Blackwell's  Island  and  on  Ward's  Island,  New  York  City,  tents  are 
in  constant  use,  with  astonishing  success  for  tuberculous  patients. 

At  the  Manhattan  State  Hospital  East,  for  the  insane,  Ward's 
Island,  New  York  City,  the  late  Dr.  A.  E.  Macdonald  instituted,  in 
1901,  a  tent  colony  for  the  tuberculous  patients. 

This  experiment  resulted  most  favorably  and  led  to  the  extension 
of  the  outdoor  treatment  to  other  classes  of  the  insane  besides  the 
consumptives.  For  thirteen  years  the  consumptive  insane  on  Ward's 
Island  have  been  treated  in  tents  and  pavilions.  Tuberculous  infec- 
tion has  been  removed  from  the  wards  and  11.39  per  cent  of  patients 
are  reported  to  have  had  their  tubercular  disease  arrested.  They 
almost  invariably  gained  flesh ;  one  is  reported  to  have  gained  79.5 
lbs.  (Eighth  Annual  Report,  Manhattan  State  Hosp.,  New  York.) 
In  the  Eighth  Annual  Report  the  following  comment  is  made :  "  In 
our  experience  the  winter  months  have  proven  to  be  the  most  favor- 
able for  these  patients,  despite  popular  opinion  to  the  contrary,  and 
likewise  it  is  seen  that  the  summer  month  of  July  was  in  a  decided 
manner  proven  to  be  the  least  favorable  of  the  year." 


1  Harper's  Magazine,  July,  1908. 


122  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

The  accompanying  illustrations  show  fully  the  initial  stage  of  this 
experiment  in  a  portion  of  New  York  City  having  many  natural 
beauties.  But  in  the  course  of  time  it  was  apparently  realized  that 
the  same  results  might  be  obtained  with  other  structures  of  a  more 
permanent  character  and  I  am  informed  by  Dr.  William  Mabon,  the 
superintendent  and  medical  director,  that  the  tents  have  been  replaced 
by  wooden  and  glass  camps.  The  reason  for  this  change  is  that 
the  tents  were  found  to  be  very  -close  and  unsatisfactory  in  wet 
weather,  whereas  the  wooden  camps  can  be  opened  and  ventilated 
under  all  conditions  of  weather. 

Pavilion  Tents. — On  Blackwell's  Island,  New  York,  the  Metropoli- 
tan Hospital  makes  use  of  twelve  pavilion  tents  with  a  capacity  for 
142  patients.  Steam  pipes  are  arranged  in  a  double  circuit  and  in 
some  cases  stoves  render  these  pavilion  tents  comfortable  in  winter 
and  were  preferred  by  the  majority  of  the  patients,  in  the  coldest 
weather,  to  the  ordinary  quarters  in  the  main  building  of  the  hos- 
pital. These  pavilion  tents  were  devised  by  Dr.  A.  M.  Holmes,  of 
Denver. 

The  tent  devised  by  Dr.  Charles  Fox  Gardiner,  of  Colorado 
Springs,  is  largely  used  in  western  sanatoria  and  has  some  notable 
advantages.  It  is  of  conical  shape,  like  the  Sibley  army  tent,  with 
a  ventilator  at  the  apex  of  the  cone  which  may  be  opened  or  shut. 
The  board  floor  has  an  air  space  beneath  and  air  inlets  opening 
at  the  floor  between  the  interior  wainscoting  and  the  tent  wall 
supplying  air  at  the  height  of  three  or  four  feet  above  the  floor. 
This  is  an  improvement  over  the  method  of  allowing  air  to  enter 
at  the  floor.  These  inlets  are  controlled  by  hinged  lids.  This  tent 
avoids  the  use  of  a  center  pole,  pegs,  or  guy-ropes,  as  it  is  sup- 
ported by  two-by-four-inch  timbers  reinforced  by  angle  irons  and 
plates.  This  tent  costs  from  $90  to  $100  and  is  thoroughly  practical. 
It  is  not  unlike  the  Nordrach  tent.     (See  plate  55.) 

The  tent  devised  by  Dr.  H.  L.  Ulrich,  of  Minneapolis,  is  simpler 
and  less  expensive.  It  consists  of  a  wall  tent  with  ridge  pole  for  the 
tent,  and  another  12  inches  clear  above  it  for  the  "fly."  There 
are  ventilating  openings  on  either  side  of  the  tent  ridge.  The  tent 
and  "  fly  "  are  secured  by  guy-ropes  and  pegs  and  all  four  sides 
may  be  rolled  up  and  lowered  as  required.  A  stove  may  be  used 
in  cold  weather.    A  tent  10  by  12  feet  costs  $22.50. 

Other  excellent  tents  have  been  devised  by  Prof.  Irving  Fisher,  of 
New  Haven,  Dr.  Mary  Lapham,  of  Highland,  N.  C.,1  and  Dr.  James 
A.  Hart,  of  Geneva,  New  York,  and  Colorado  Springs. 


1  American  Medicine,  Phila.,  1905,  Vol.  9,  517. 


Smithsonian  miscellane;us  collections 


VCL.     63,     NO.    1,     PL.    53 


FIG.  1.     MANHATTAN  STATE  HOSPITAL,   EAST,  WARD'S  ISLAND,   NEW  YORK  CITY. 

THE  TUBERCULOUS  INSANE 


TENTS  FOR 


MANHATTAN  STATE  HOSPITAL,   EAST,  WARD'S  ISLAND,  NEW  YORK  CITY.     CAMP  C,  FOR 
DEMENTED  AND  UNCLEANLY  TUBERCULOSIS   INSANE   PATIENTS 


8MITH80NIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    I,    PL.    ti 


FIG.   1.     MANHATTAN  STATE    HOSPITAL,   EAST,  WARD'S  ISLAND,   NEW   YORK  CITY.     TENTS  FOR 
THE  TUBERCULOUS  INSANE.     SUMMER   LOCATION 


MANHATTAN   STATE   HOSPITAL,  EAST,  WARD'S  ISLAND,  NEW  YORK  CITY. 
THE  TUBERCULOUS   INSANE.     SUMMER   LOCATION 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    56 


FIG.  1.     TENT  DEVISED  BY   DR.  CHARLES  F.   GARDINER,  COLORADO 
SPRINGS.     SEE   PAGE  122 


FIG.  2.  MANHATTAN  STATE  HOSPITAL,  EAST  .  CAMP  A.  INSANE  TUBERCULOUS  PATIENTS. 
REVOLVING  TENT  CONSTRUCTED  SO  AS  TO  BE  EASILY  TURNED  IN  ACCORDANCE  WITH  THE  DIREC- 
TION  OF  SUN   AND  WIND. 


(3   id 


z"m  ? 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    57 


FIG.    1.       MANHATTAN   STATE    HOSPITAL,    EAST,  WARD'S    ISLAND,     NEW   YORK    CITY.      NEW    OPEN 
SHELTER   FOR  THE  TUBERCULOUS   INSANE 


FIG.  2.      LOOMIS  SANATORIUM,  SULLIVAN   COUNTY,    NEW  YORK.     SLEEPING  GALLERY   IN 

GUILD  LEAN-TO 


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NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  123 

The  evolution  of  the  tent  and  open  air  shelter  into  the  tent  house, 
shack,  and  cottage,  is  an  interesting  feature  of  the  open  air  treatment 
of  tuberculosis. 

"Lean-to." — The  open  air  shelter  and  "lean-to"  are  somewhat 
alike.  The  latter  has  been  long  used  by  sportsmen  and  others  in 
our  northern  forests,  and  has  been  greatly  amplified  for  sanatorium 
purposes.  The  roof  of  the  "  lean-to  "  slopes  directly  back  from  its 
front  or  there  may  be  a  ridge  placed  close  to  the  front  or  southerly 
side  of  the  structure.  The  roof  slopes  well  toward  the  back,  but  is 
short  in  front  and  allows  free  access  of  air  and  light.  Canvass  or 
screens  are  arranged  to  hang  in  front  as  a  protection  from  wind  or 
rain,  and  to  insure  privacy.  For  a  full  description  of  a  "  lean-to  " 
the  reader  is  referred  to  Dr.  H.  M.  King's  description  with  plans  in 
"  Some  Methods  of  Housing,"  Charity  Organization  Society,  New 
York. 

Excellent  "  lean-tos  "  or  open  air  shelters  are  in  use  all  the  year 
at  the  Royal  Victoria  Hospital,  Edinburgh,  Scotland,  as  seen  in  the 
illustration  kindly  supplied  by  Sir  Robert  Philip.     (See  plate  56.) 

Pavilion  tents  are  amplifications  of  the  tent  cottage,  and  are 
adapted  for  ten  or  twelve  beds.  As  described  by  Mr.  Homer  Folks, 
they  are  sixteen  by  thirty-two  feet  long;  the  walls  are  eight  feet 
high ;  the  roof  is  fifteen  feet  high  at  the  ridge  and  the  floor  of  the 
tent  is  sixteen  inches  above  the  ground  with  free  circulation  of  air 
underneath. 

Tent  Houses  adapted  for  use  in  the  New  England  and  Middle 
States  are  naturally  different  from  those  in  use  in  New  Mexico  and 
Arizona,  where  rain  and  snow  are  uncommon.  The  accompanying 
illustrations  show  a  row  of  six  tent  houses  and  a  single  tent  house 
at  the  U.  S.  Public  Health  Sanatorium  at  Fort  Stanton,  New  Mexico, 
for  consumptive  sailors,  under  the  care  of  the  United  States  Public 
Health  Service.  The  roof  has  a  slight  incline  and  the  sides  are  ar- 
ranged to  give  free  ventilation  as  well  as  shelter  when  required. 

Trolley  Cars. — Superannuated  and  disused  trolley  cars  were  first 
used  for  tuberculosis  patients  by  Dr.  W.  H.  Peters,  of  Providence, 
Rhode  Island,  at  the  Pine  Ridge  Camp  near  that  city.  With  slight 
alterations  and  at  very  little  expense  these  cars  may  serve  a  useful 
purpose  in  connection  with  the  outdoor  treatment  of  tuberculosis  at 
all  seasons.  Once  located  on  a  convenient  site  they  have  many  ad- 
vantages over  the  ordinary  shack,  affording  a  maximum  of  light  and 
air  and  good  protection  against  storms  with  their  adjustable  windows 
and  doors.    The  author  visited  Pine  Ridge  Camp  and  can  testify  to 


124  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

their  efficiency ;  the  camp  itself  was  discontinued  after  the  erection 
of  the  fine  State  Sanatorium  for  tuberculosis  at  Wallum  Lake. 
Trolley  cars  were  also  used  at  the  Camp  Auxiliary,  Montefiore  Home, 
Bedford,  New  York.     (See  plates  67  and  68.) 

The  Balcony,  or  Liege-terrasse  as  it  is  known  in  Germany,  is  a  nec- 
essary adjunct  of  any  sanatorium  for  tuberculosis.  Plate  71  shows  a 
covered  or  partly  sheltered  balcony  in  use  at  a  large  private  sana- 
torium in  St.  Blasien  in  the  Black  Forest,  Germany.  Plate  89  shows 
an  open  or  uncovered  balcony  at  the  Sharon  Sanatorium,  Massa- 
chusetts. In  June,  1908,  the  author  visited  the  latter  sanatorium  with 
the  Medical  Director,  Dr.  Vincent  Y.  Bowditch,  and  can  bear  wit- 
ness to  the  excellent  arrangements  for  the  outdoor  treatment  of 
tuberculosis  carried  out  at  this  institution. 

The  records,  now  extending  over  22  years,  show  that  about  50 
per  cent  of  all  cases,  and  72  per  cent  of  all  incipient  cases  have  been 
arrested  or  cured.1  Of  the  160  arrested  cases  treated  between  1891 
and  1906,  133  or  83  per  cent  were  still  living  and  well  in  1908,  most 
of  them  house-keepers  and  wage  earners;  in  addition,  3.7  per  cent 
were  doing  well  at  last  accounts,  but  were  not  recently  heard  from. 

We  have  given  the  particulars  of  these  cases  treated  at  Sharon 
Sanatorium  because  the  results  are  remarkably  good  being  obtained 
at  an  elevation  of  250  feet  above  sea  level,  about  15  miles  from 
Massachusetts  Bay,  and  about  20  miles  from  Boston.  Sharon  is  near 
enough  to  the  ocean  to  be  affected  by  the  sea  breeze  during  the  hot 
weather. 

Day  Camps;  Walderholungst'dtten. — The  daily  care  of  consump- 
tives at  a  day  camp  for  the  outpatients  of  a  general  hospital  had  its 
origin  about  the  same  time  in  both  Boston  and  Berlin.  It  was  pro- 
posed by  Dr.  A.  K.  Stone  and  Dr.  E.  P.  Joslin  in  1905  in  Boston, 
and  provision  was  made  at  the  Mattapan  Day  Camps  and  at  the 
House  of  the  Good  Samaritan  for  ambulatory  patients.  Plates  72-74 
show  how  this  is  carried  out.  In  July,  1908,  fifty  consumptives  too 
ill  to  be  benefited  by  treatment  at  the  Massachusetts  General  Hos- 
pital were  transferred  to  the  new  home  of  the  Boston  Consumptives' 
Hospital  on  the  Conness  estate,  Mattapan,  and  entered  on  treatment 
which  it  was  hoped  would  culminate  in  their  improvement  to  an  ex- 
tent that  should  warrant  their  entrance  into  the  state  institution. 
They  went  to  the  camp  in  the  morning  and  returned  to  their  homes 


1  See  V.  Y.  Bowditch,   Boston   Medical  and   Surg.   Journ.,   June  22,   1899. 
See  V.  Y.  Bowditch,    Journ.    Amer.    Med.    Ass.,    Nov.    14,    1903. 
See  V.  Y.  Bowditch,  Trans.   Amer.   Climatological  Ass.,   1907,   p.    168. 


SMITHSONIAN    MI8CE LLANEOU8    COLLECTIONS 


VOL.    63,    NO.    1,    PL. 


OLD  TROLLEY   CAR  THAT  WAS    USED    BY    MOTHER    AND  CHILD  AT  THE    PINE   RIDGE 
CAMP  FOR   CONSUMPTIVES,   NEAR    PROVIDENCE,   RHODE  ISLAND 
Photograph   by  Courtesy  of  Dr.   W.   H.   Peters,   Providence 


FIG.  2.  ESTES  PARK,  COLORADO.  IDEAL  SUMMER  RESIDENCE,  WITH  SPACIOUS  PORCHES  FOR 
PULMONARY  INVALIDS.  SLOPING  GROUND,  SANDY  SOIL,  MOUNTAINOUS  BACK-GROUND  AFFORDING 
PROTECTION   FROM  WIND  AND  DUST. 

Courtesy  of  Dr.  S.  G.  Bonney 


t  ~ 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  1 25 

at  night.  Those  given  preference  in  treatment  were  patients  whose 
dependents,  circumstances,  and  health  most  demanded  it.  The  new 
hospital  and  its  location  are  picturesque  as  well  as  healthful,  and 
patients  are  able  to  remain  throughout  the  winter.  The  main  build- 
ing is  125  feet  long  and  contains  dining-room,  kitchen,  examination 
and  rest  rooms,  and  has  a  spacious  veranda  facing  the  south.  It  is 
designed  to  accommodate  150  patients,  in  the  two  pavilions,  two  cot- 
tages, and  children's  building.  The  Day  Camp  has  proved  to  be  a 
great  success. 

Day  camps,  when  properly  conducted,  have  an  immense  value  on 
educational  lines.  In  addition  they  remove  for  a  time  the  sources 
of  infection  from  the  community  and  from  the  homes.  These 
patients  cannot  always  go  to  a  sanatorium  but  in  this  way  receive 
proper  care  during  a  large  part  of  the  day  and  may  eventually  avoid 
the  necessity  of  going  to  a  sanatorium;  others  who  need  sanatorium 
care  are  provided  for,  pending  admission ;  and  after  discharge  from 
the  sanatorium  the  camp  helps  to  complete  the  cure.  Dr.  Otis  does 
not  believe  that  these  camps  are  destined  to  become  a  permanent 
therapeutic  measure  in  conducting  the  cure. 

The  best  location  for  day  camps  is  in  the  forest.  In  Germany  they 
are  known  as  Walderholungstatte  and  there  are  over  eighty  of  them 
scattered  throughout  the  Empire.  Those  who  are  only  slightly  af- 
fected with  tuberculosis,  or  are  convalescent  from  it,  pass  the  day  in 
camp  and  return  at  night  to  their  homes.  The  accompanying  illus- 
tration (pi.  76)  shows  these  camps  for  adults  and  children  at 
Kuhfelde,  Germany.  These  forest  convalescent  homes  are  greatly 
favored  by  the  German  insurance  societies  and  sick  lodges.  Their 
benefits  are  extended  to  the  children  of  patients. 

Germany  must  be  given  credit  for  making  the  greatest  discoveries 
and  for  instituting  the  most  rational  methods  of  treatment  in  connec- 
tion with  tuberculosis.  The  most  thorough  measures  are  adopted 
by  the  Imperial  Government,  the  industrial  insurance  companies  and 
by  the  medical  profession  of  Germany. 

According  to  the  business  report  of  the  German  Central  Com- 
mittee for  the  campaign  against  tuberculosis,  there  were  in  Germany 
in  1908  99  popular  sanatoria  for  adults  affected  with  disease  of  the 
lungs.  These  have  10,539  beds,  6,500  for  men  and  4,039  for  women  ; 
in  addition  there  are  36  private  sanatoria  with  2,175  beds,  so  that 
in  all,  12,714  beds  for  adult  tuberculosis  patients  are  available.  For 
children  with  pronounced  tuberculosis  there  are  18  sanatoria  with 
875  beds ;  besides  there  are  J^>  institutions,  with  6,348  beds,  in  which 


126  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

are  received  only  "  scrofulous  "  children  and  those  who  are  threat- 
ened with  tuberculosis.  During  the  last  five  years  these  facilities 
have  been  greatly  increased;  31,022  insured  persons  were  treated 
in  the  sanatoria  during  a  total  of  2,312,850  days  of  care,  at  a  cost  of 
11,483,033  marks  ($2,755,928).  On  an  average,  each  person  treated 
received  75  days  of  care  at  a  cost  of  370.16  marks  ($88.84)  or  4-9^ 
marks  ($1.19)  per  person  for  each  day  of  care. 

Night  Camps. — These  afford  open  air  conditions  of  sleeping,  either 
for  patients  with  arrested  tuberculosis  who  pursue  their  occupation 
by  day  in  the  nearby  city,  or  with  disease  still  unarrested  but  who  are 
able,  or  from  necessity  are  compelled  to  work  by  day.1 

Sleeping  porches  and  balconies. — Sleeping  out  of  doors  requires 
special  arrangements  which  are  not  usually  found  in  cities.  The 
ordinary  dwelling,  apartment  house,  or  tenement  has  no  provision  for 
this  innovation  in  tuberculo-therapy.  Suburban  and  country  houses 
or  those  in  the  less  crowded  cities  are  better  adapted  for  the  con- 
version of  an  upper  porch  or  balcony  into  a  sleeping  apartment. 
In  Denver,  for  instance,  the  practice  is  common  enough  to  excite 
little  comment.  Detached  houses  are  usually  easily  fitted  with  the 
necessary  screened  enclosures.2 

Pavilions  are  more  substantial  and  permanent  than  the  forms  of 
shelter  previously  referred  to.  Where  large  numbers  of  patients 
must  be  cared  for  at  a  minimum  of  expense  the  pavilion  system  has 
distinct  advantages,  especially  for  night  use.  At  the  Metropolitan 
Hospital,  Blackwell's  Island,  New  York  City,  about  one-third  of  all 
consumptives  under  hospital  care  in  New  York  are  there  provided 
for  in  the  tent  pavilions  referred  to  on  page  123  ;  these  tent  pavilions 
cost  about  $12.00  per  bed  or  $144.00  for  a  tent  pavilion  with  a  capac- 
ity of  12  beds. 

At  the  Manhattan  State  Hospital  for  the  Insane,  Ward's  Island, 
New  York,  more  substantial  and  permanent  pavilions  have  been  con- 
structed of  wood  and  glass  and  have  displaced  the  cloth  tents.  These 
pavilions  are  heated  by  steam,  lighted  by  electricity,  and  have  remov- 
able glass  sides  permitting  a  free  circulation  of  air  and  light  all  the 
time.    Their  per  capita  cost  is  about  $100. 

In  addition,  there  are  camps  for  both  the  men  and  the  women 
with  a  total  capacity  of  175  patients.    In  summer  some  canvas  tents 


1  E.  O.  Otis :  Institutions  for  the  Prevention  and  Cure  of  Tuberculosis, 
Boston  Med.  and  Surg.  Journ.,  Aug.  1,  1912. 

2  See  "  Directions  for  Living  and  Sleeping  in  the  Open  Air,"  National  Ass. 
Tuberculosis,  1910.  See  T.  S.  Carrington :  Interstate  Med.  Journ.,  April, 
1914. 


LU  I 

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SMITHSONIAN     MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    72 


DAY  CAMP  FOR  TUBERCULOSIS  PATIENTS, 
SAMARITAN,  BOSTON 


HOUSE  OF  THE  GOOD 


DAY  CAMP  FOR  TUBERCULOUS  PATIENTS  AT  THE  HOUSE  OF  THE  GOOD 
SAMARITAN,  BOSTON,  NEAR  THE  HARVARD  MEDICAL  SCHOOL 


£  5 


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SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.     1,     PL.    77 


FIG.   1       DIET  KITCHEN.     DAY  CAMP  AT  PARKER   HILL,   BOSTON,   MASSACHUSETTS 


FIG.  2.     SLEEPING  BALCONY  USED  BY  A  PATIENT  IN   HAVERHILL,   MASSACHUSETTS 


SMITHSONIAN     MISCELLANEOUS    COLLECTIONS 


VOL.    83,    NO.    I,    PL.    78 


SLEEPING   PORCH   IN   A  CROWDED   DISTRICT  OF    PHILADELPHIA 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL,    79 


DOUBLE  SLEEPING  PORCH  WITH  EASTERN  AND  SOUTHERN  EXPOSURES.  THIS  SUMMER  RESI- 
DENCE IN  ESTES  PARK,  COLORADO,  IS  PROVIDED  WITH  PORCHES  ON  ALL  SIDES  SAVE  THE  NORTH, 
WHICH  IS  PROTECTED  BY  THE  ROCKY  FORMATION  IN  THE  BACKGROUND.  THE  PORCH  IS  COV- 
ERED WITH   A  PERMANENT  ROOF. 

Courtesy  of  Dr.  S.   G.   Bonney 


SMITHSONIAN     MISCELLANEOUS    COLLECTIONS 


VOl  .    61,    NO.    I  ,    PL.    80 


CITY  RESIDENCE  WITH  IDEAL  UPPER  DOUBLE  SLEEPING  PORCH  CONNECTED 
WITH  BEDROOM.  SHEATHING  AT  THE  BASE,  WIRE  SCREENING,  AWNINGS, 
ELECTRIC   LIGHT. 

Courtesy  of  Dr.  S.  G.   Bonney,   Denver 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    83 


FIG.   1.     MANHATTAN   STATE  HOSPITAL,   EAST,  WARD'S  ISLAND,   NEW  YORK  CITY.       NEW  PAVILIONS 

FOR  THE  TUBERCULOUS  INSANE. 

Courtesy  of  Dr.  William  Mabon 


FIG.  2.     MANHATTAN   STATE  HOSPITAL,   EAST,   WARD'S  ISLAND,   NEW  YORK  CITY.     NEW  GLASS 

PAVILION    FOR  THE  TUBERCULOUS  INSANE.     WINTER 

Courtesy  of  Dr   William  Mabon 


>    ~ 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    85 


FIG     1.     KIOSK  AND  OPEN   DECK  ADJOINING  WARDS  FOR   EARLY  CASES  OF  TUBERCULOSIS     PHIPPS 

INSTITUTE,  IN   A  VERY  OLD  AND  CROWDED  PART  OF  PHILADELPHIA 

Courtesy  of  Dr.  C.  J.  Hatfield,  Director 


FIG.  2.     BELLEVUE  HOSPITAL,  NEW  YORK  CITY.      ROOF  WARD  FOR  CHILDREN 
Courtesy  of  Dr.  .1.  W.  Brannan 


NO.    I  AIR    AND   TUBER<  QLOSIS — HINSDALE  I2J 

are  used.  The  accompanying  photograph  (pi.  83 ),  kindly  furnished 
by  Dr.  Wm.  Mabon,  the  superintendent,  shows  the  character  of  the 
pavilion. 

In  the  Royal  Victoria  Hospital  for  Consumptives,  Edinburgh, 
Scotland,  still  more  substantial  and  expensive  pavilions  are  in  use 
as  seen  from  the  illustrations  (pi.  84)  kindly  furnished  by  Dr.  R. 
W.  Philip. 

Roof  Gardens. — At  the  Philadelphia  Hospital  the  first  attempt  to 
segregate  tuberculous  patients  for  the  fresh  air  cure  was  by  means 
of  a  roof  garden  ward.  This  was  a  vast  improvement  over  the  pre- 
vious method  of  indoor  confinement  and  was  greatly  appreciated  by 
the  patients.  The  roof  garden  ward  was  in  use  winter  and  summer, 
but  later  gave  way  to  the  six  glass  pavilions  erected  at  an  expense 
of  over  $112,000. 

Each  pavilion  is  intended  to  accommodate  eighteen  patients,  usu- 
ally in  an  advanced  stage  of  tuberculosis.  Each  is  separate  in  itself 
with  walls  and  roof  of  glass  and  only  sufficient  metal  work  to  give 
proper  support.  The  floors  are  of  cement  so  as  to  be  as  smooth  and 
non-absorbent  as  possible.  Including  the  porches,  which  are  also 
enclosed  in  glass,  each  pavilion  measures  39  by  70  feet.  The  glass 
is  arranged  in  frames  in  both  walls  and  porches  and  by  means  of 
automatic  devices  one  side  of  the  building  or  all  three  sides  may 
be  thrown  open.  Screens  or  shades  are  arranged  to  prevent  too 
much  access  of  the  sun.  The  system  of  ventilation  and  heating  is 
considered  ample. 

Detached  Cottages. — At  the  Nordrach  Ranch  Sanatorium,  three 
miles  from  Colorado  Springs,  independent  cottages  resembling  tents 
are  used.  These  are  economical  and  insure  privacy  and  sufficient 
protection.  The  system  is  adopted  from  that  in  use  in  Nordrach, 
Germany. 

The  highest  development  of  housing  for  the  tuberculous  patient 
is  undoubtedly  the  independent  cottage.  It  is  necessarily  expensive, 
but  the  patient  fortunate  enough  to  be  its  inmate  has  a  maximum  of 
comfort  and  at  the  same  time  is  in  the  enjoyment  of  the  best  atmos- 
pheric conditions  night  and  day.  At  the  Loomis  Sanatorium  where 
the  snow  lies  on  the  ground  more  than  four  months  in  the  year,  and 
at  Saranac  Lake,  in  the  Adirondack  Mountains,  where  the  winters 
are  even  longer  and  more  severe,  the  independent  cottage  is  a  dis- 
tinctive feature. 

Sleeping  Canopies. — Detachable  windows  may  be  applied  to  tents, 
pavilions,  or  ordinary  dwellings,  so  as  to  allow  patients  to  breathe 
is 


128  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

by  day  and  night  the  outer  air  uncontaminated  by  others  occupying 
the  same  room  or  dwelling.  Devices  suitable  for  any  window  may 
be  obtained.  It  is  thus  possible  in  a  hospital  ward  to  have  half  a 
dozen  patients  breathe  the  outer  air  while  the  ward  is  kept  warm. 
The  tent  can  come  over  the  end  of  the  regular  hospital  bed  so  that 
patients  sleeping  in  wards  where  miscellaneous  cases  are  received, 
may  nevertheless  have  the  full  benefit  of  the  outer  air.  By  means 
of  thick  celluloid  the  patient  may  be  readily  seen.  The  celluloid 
window  may  be  raised  to  give  the  patient  drink  and  nourishment. 

Plate  93  shows  the  Walsh  Window  Tent  applied  to  the  window 
of  an  ordinary  dwelling.1 

CHAPTER    X.     CONCLUSIONS. 

There  are  some  people,  especially  those  of  a  skeptical  or  combative 
tendency,  who  refuse  to  admit  that  climate  plays  any  important  role 
in  the  cure  of  tuberculosis.  One  of  these  who  was  formerly  in  charge 
of  a  widely  known  institution  for  the  study  and  treatment  of  tuber- 
culosis has  said :  "  I  desire  to  go  on  record  as  believing  that  there 
is  no  therapeutic  value  in  climate."  This  same  physician  probably 
owes  his  life  to  the  fact  that  thirty-five  years  or  more  ago  he  left 
the  city  and  removed  to  the  mountains  of  Pennsylvania  for  the  relief 
of  a  pulmonary  disease  and  recovered.  Such  an  attitude  is  a  study 
for  the  psychologists  and  would  hardly  seem  deserving  of  serious 
attention,  except  that  we  hear  such  statements  as  this:  "If  a  case 
of  consumption  cannot  be  cured  in  its  home  climate  it  cannot  be 
cured  anywhere." 

I  think  there  is  no  doubt  that  if  any  of  us  were  told  that  he  is 
in  the  incipient  stage  of  tuberculosis  he  would  immediately  take  steps 
to  familiarize  himself  with  the  line  of  treatment  which  would,  before 
much  time  had  elasped,  involve  leaving  Boston,  New  York,  Phila- 
delphia, or  Chicago,  as  the  case  might  be,  and  so  live  as  to  enjoy 
what  air  and  sunshine  and  other  atmospheric  features  might  afford. 

One  reason  why  home  climates,  if  such  a  term  may  be  permissible, 
have  grown  in  favor  is  that  it  has  been  found  necessary  to  estab- 
lish a  large  number  of  State  sanatoria,  or  at  least  to  seek  aid  for 
private  sanatoria  from  some  of  our  State  legislatures.  It  is  a  matter 
of  expediency  to  have  such  sanatoria  and  legislators  must  be  con- 
vinced that  good  results  or,  if  necessary,  the  best  results,  can  be 
obtained  close  at  hand.    We  are  all  heartily  in  favor  of  such  institu- 


1  For  the  history  of  this  tent  see  Knopf  and  McLaughlin,  N.  Y.  Med.  Journ., 
1905,  Vol.  81,  425. 


NO.    I  AIR   AND*  TUBERCULOSIS — HINSDALE  1 29 

tions  whether  or  not  we  should  wish  to  stake  our  chances  of  recovery 
in  any  of  them. 

Of  course  we  do  not  claim  that  there  is  any  specific  climate  for 
tuberculosis  and  the  long  search  for  such  climate,  a  search  lasting 
for  nearly  two  thousand  years,  is  apparently  at  an  end. 

Now  what  is  there  left  to  us,  and  what  do  we  understand  by  a 
climatic  change? 

We  all  know  that  the  New  England  climate  is  changeable,  that  is, 
the  meteorological  conditions  are  constantly  varying  just  as  they 
also  vary  in  the  Mississippi  Valley  and  along  the  Atlantic  seaboard. 
But  the  New  England  climate  is  peculiarly  unstable  and,  as  Charles 
Dudley  Warner  has  said,  "  New  England  is  the  battle-ground  of 
the  weather." 

We  have  a  change  of  climate  when  we  leave  the  hot  city  in  summer 
and  go  a  few  miles  to  the  shore.  We  have  floating  hospitals  so  that  this 
climatic  change  may  stimulate  a  sick  child  to  recovery.  A  so-called 
"  home-climate  "  may  work  a  cure  or  aid  in  a  cure  because  we  leave 
the  climate  of  our  homes,  often  too  dry  with  furnace  heat,  too  poorly 
ventilated,  too  damp  from  lack  of  sun,  and  remove  to  more  hygienic 
dwellings  in  the  same  locality  where  sun  and  air  and  cleanliness 
abound. 

But,  to  take  up  the  principal  question  at  issue,  the  first  thing  usu- 
ally asked  is  whether  one  should  go  to  the  Adirondacks,  Colorado, 
New  Mexico,  Arizona,  California,  or  elsewhere,  in  order  to  get 
what  is  so  frequently  claimed  to  be  the  greatest  climatic  advantages. 
No  one  who  has  visited  these  localities  can  fail  to  be  impressed  with 
the  living  examples  of  recovery  from  tuberculosis.  Denver,  Colo- 
rado Springs,  and  innumerable  towns  in  southern  California  abound 
in  doctors  who  have  practically  recovered  from  this  disease  and  are 
earning  a  living  that  is  the  envy  of  their  eastern  confreres. 

Would  they  have  recovered  in  their  eastern  homes  ?  Almost  to  a 
man  they  answer  "  No."  I  have  never  heard  of  an  exception.  But 
the  case  is  hard  to  prove  from  such  ex  parte  evidence.  However, 
it  is  interesting  to  note  Dr.  H.  B.  Dunham's  conclusion.  He  stated 
in  1904,  after-  visiting  discharged  Massachusetts  State  Sanatorium 
patients  in  the  west,  and  after  comparing  Massachusetts  Sanatorium 
statistics  with  those  of  the  U.  S.  Army  Sanatorium  at  Fort  Bayard, 
New  Mexico,  that  "  the  results  corroborate  our  beliefs  in  the  effi- 
cacy of  residence  in  dry  climates,  but  with  a  smaller  margin  in  its 
favor  than  was  anticipated."  The  proportion  of  people  adapted  for 
treatment  in  these  extremes  of  climate  must  be  more  equal  than 


130  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

thought  possible  by  climatologists  generally.  That  is  to  say,  a  small 
majority  of  the  patients  at  Rutland,  Mass.,  would  probably  do  better 
at  Fort  Bayard,  New  Mexico,  and  a  large  minority  might  do  better 
at  Rutland.  But  no  one  can  say  positively,  in  any  given  case,  what 
would  have  been  the  outcome  had  he  chosen  differently. 

We  need  not  discuss  the  bearing  of  what  to  do  for  the  poor  or 
what  to  do  for  the  rich,  or  the  question  of  food,  or  the  physician's 
management ;  these  are  important  and  may  govern  the  choice,  but 
what  we  want  is  an  answer  to  the  abstract  question  of  the  influence 
of  climate. 

We  believe  that  climate  may  be  utilized  as  an  adjuvant  of  great 
value  for  carrying  out  the  hygienic,  dietetic  treatment  of  all  forms 
of  tuberculosis  and  of  many  other  diseases.  There  are  some  elements 
of  climate  that  have  a  more  positive  influence  in  hastening  cure  than 
others.  The  first  place  must  be  assigned  to  an  abundance  of  air, 
which  is  as  nearly  as  possible  bacteriologically  and  chemically  pure. 
It  goes  without  saying  that  city  air  is  polluted  by  smoke  and  dust 
and  all  dwellings,  whether  in  the  city  or  the  country,  are  far  below 
the  standard  of  purity  desirable.  Only  on  the  sea  or  at  the  highest 
elevations  do  we  find  air  really  pure,  but  we  can  approximate  it  by 
living  out  of  doors.  There  is  a  climate  of  the  city,  a  suburban 
climate,  a  climate  of  the  country,  woods,  and  plains,  all  differing 
as  regards  purity  of  air.    We  are  all  probably  agreed  on  this  point. 

Next  comes  the  subject  of  sunshine.  We  admit  that  good  results 
are  obtained  in  cloudy  regions  as,  for  instance,  in  the  Adirondacks 
and  at  Rutland ;  but  there  is  at  least  no  objection  to  sunshine,  andT 
believe  that  the  moral  effect  of  bright  sunny  days  and  plenty  of  them 
is  very  great.  Invalids  always  welcome  the  sun.  We  can  protect 
ourselves  from  too  much  sun  if  need  be,  and  I,  for  one,  believe  that 
sunlight  does  a  vast  amount  of  good  and  sunny  regions  are  much  to 
be  preferred,  other  things  being  equal.  That  is  the  great  asset  of 
our  western  plains  and  mountains ;  and  it  is  a  real  asset  that  counts. 
Of  course  there  are  exceptions.  Tastes  differ.  Dr.  Solly  used  to 
relate  the  story  of  one  of  his  countrymen  who  had  been  sojourning 
in  Colorado  and  finally  returned  to  England.  As  he  landed  in  a  fog 
and  found  himself  home  again,  he  exclaimed,  "  Thank  God !  I  am 
out  of  that  beastly  sunshine."  I  do  not  suppose  he  intended  to  be 
irrational  or  ungrateful  for  the  greatest  of  all  natural  gifts. 

Now,  what  other  climatic  conditions  besides  pure  air  and  abundant 
sunshine  have  we  to  help  us?  Is  a  cool  climate  or  a  warm  climate 
the  best?    Is  a  dry  or  humid  climate  to  be  preferred?    These  quali- 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    89 


FIG.  1.     SHACK  WITH  SCREENED  PORCH.     ESTES  PARK,  COLORADO 
Courtesy  of  Dr.  S.  G.  Bonney 


FIG.  2.      WELCH'S  RESORT,   FIVE  MILES   FROM   LYONS,  COLORADO.      SIX  ROOM  COTTAGE  SOME- 
WHAT   PRIMITIVE    BUT    WITH    AMPLE    SCREENED    PORCH.       SHELTERED    FROM    NORTH    AND    WEST 

WINDS. 

Courtesy  of  Dr.  S.  G.  Bonney 


O    00 
«!   CD 


fcKflwyi 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL. 


FIG.   1.     ANNE   M.   LOOMIS  MEMORIAL    COTTAGE— (NEW    INDEPENDENT    UNIT)    LOOMIS   SANATORIUM 

SULLIVAN  COUNTY,   NEW  YORK 


FIG.  2.     LOOMIS  SANATORIUM,  SULLIVAN   COUNTY,   NEW  YORK.     ONE  OF  THE   EAST   PORCHES  OF 
THE   MARY   LEWIS  RECEPTION   HOSPITAL 


NO.    I  AIR    AND    TUBERCULOSIS HINSDALE  131 

ties  of  temperature  and  humidity  may  as  well  be  considered  together. 
Undoubtedly  for  the  majority  of  cases  in  the  first  stage  the  climate 
should  be  dry  and  the  temperature  comfortable — not  warm  enough  to 
be  relaxing,  but  not  so  cold  as  to  be  repellent  and  restrict  exercise  or 
out-of-door  life.  It  is  true  that  in  special  localities  better  results 
are  obtained  during  the  cold  months  than  during  the  summer.  This 
is  true  of  the  Adirondack  Cottage  Sanitarium  in  the  State  of  New 
York.  One  reason  for  this  is  that  in  winter  the  lakes  and  ponds 
are  frozen  and  covered  with  dry  snow ;  the  air  is  drier.  It  is  far 
enough  north  and  at  a  sufficient  altitude  to  escape  the  alternate  freez- 
ing and  thawing  that  is  experienced  in  New  York  City,  where  un- 
questionably it  is  less  favorable  for  the  consumptive  during  the  cold 
season  than  during  the  warm  months.  Take  Florida  and  South 
Carolina:  Undoubtedly  the  best  season  there  is  during  the  winter 
months,  as  the  summers  are  oppressively  warm  and  wet.  The 
winter  is  the  dry  season  and  the  temperature  is  comfortable.  The 
interior  of  Florida  forty  or  fifty  miles  from  either  coast  is  reasonably 
dry.  As  far  as  Arizona  and  New  Mexico  are  concerned,  the  sum- 
mers are  too  hot  at  all  the  lower  elevations  for  any  invalid,  but  at 
the  higher  elevations,  5,000  or  6,000  or  7,000  feet,  the  summer  heat 
is  not  oppressive.  Along  the  southern  coast  of  California  and  at 
many  of  the  resorts  somewhat  inland,  as  good  results  are  obtained 
in  summer  as  in  winter,  although  the  latter  is  the  more  fashionable 
season  for  eastern  visitors.  The  southern  California  resorts  which 
have  been  most  frequented  by  consumptives  vary  greatly  between 
themselves  as  regards  the  important  question  of  humidity.  That  a 
place  is  frequented  by  consumptives  does  not  prove  that  it  is  a  desir- 
able place  for  them.  Many  of  them  are  misguided,  wandering  in- 
valids, sent  out  from  the  east  with  little  or  no  judgment  as  to  their 
individual  needs  and  with  no  proper  knowledge  on  the  part  of  their 
medical  advisers  as  to  the  humidity  or  local  character  of  the  places 
to  which  they  are  destined.  A  man,  for  instance,  will  go  to  Los 
Angeles.  It  does  not  take  him  long  to  find  out  that  while  the  air 
is  fairly  dry  from  11  a.  m.  to  5  p.  m.,  it  is  always  damp  at  night. 
Six  hours  out  of  twenty-four  are  dry,  the  remaining  eighteen  are 
decidedly  damp.  The  physicians  of  Los  Angeles  do  not  claim  that 
their  climate  is  a  suitable  one  for  cases  of  tuberculosis  and  usually 
send  these  cases  to  the  interior  stations,  such  as  Redlands  or  River- 
side, Monrovia  or  Altadena.  Many  are  sent  to  Arizona.  Experience 
shows  that  consumptives  do  better  if  they  avoid  the  coast  region. 
Or,  if  near  the  coast,  as  at  Santa  Barbara,  they  are  better  if  they 


I32  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

find  a  site  at  some  elevation  on  the  hillside  or  in  the  mountain  val- 
leys beyond  the  reach  of  the  morning  fog  and  the  excessive  humidity 
at  the  shore.1  The  records  of  the  Weather  Bureau  show  that  these 
places  on  the  coast  or  within  reach  of  the  fogs  which  penetrate 
inland  have  a  greater  humidity  than  Boston  or  New  York,  the  mean 
annual  absolute  humidity  for  Santa  Barbara,  Los  Angeles,  and  San 
Diego  being  given  at  4.20,  4.42  and  4.34  grains,  more  than  one-third 
more  than  that  of  New  York  and  Boston,  3.19  grains  and  2.84  grains. 
The  mean  annual  relative  humidity  of  all  these  places  mentioned  is 
from  72  to  73  per  cent.  But  the  advantage  of  places  like  Santa  Bar- 
bara, San  Diego,  Redlands,  and  Riverside,  lies  in  the  fact  that  the 
mean  annual  humidity  shows  a  remarkable  variation  during  the 
twenty-four  hours  compared  with  places  like  Boston,  New  York,  or 
Philadelphia,  where  the  daily  range  is  much  less.  At  Redlands,  fifty 
miles  inland  from  the  Pacific  Ocean,  one  of  the  best  known  stations, 
the  hygrometer  has  been  known  to  indicate  in  fair  weather  55  per  cent 
at  4.30  p.  m.,  and  80  per  cent  at  6.00  p.  m.  The  relative  humidity 
is  sometimes  as  low  as  30  per  cent  for  a  limited  time  during  the 
day,  and  70  to  80  per  cent  at  night  when  the  temperature  is  from 
440  to  6o°  F. 

It  may  as  well  be  stated  that  the  government  records  of  humidity 
are  quite  misleading  when  we  use  them  to  judge  of  the  climate  of 
any  given  place.  The  observations  are  made  at  8  a.  m.  and  8  p.  m., 
but  in  the  invalid's  day,  made  up  of  the  intervening  hours,  the  rela- 
tive humidity  reaches  a  much  lower  mark  than  the  records  show. 
I  often  observe  a  relative  humidity  in  Virginia  of  25  or  30  per  cent 
at  2  p.  m.,  and  95  or  98  per  cent  at  night  or  in  the  early  morning, 
especially  when  dew  falls  after  a  bright,  invigorating  day.  I  think 
that  people,  whether  sick  or  well,  adjust  themselves  to  these  natural 
changes  of  humidity  if  properly  clothed  and  constantly  in  the  open 
air ;  but  when  subject  to  rapid  changes  in  humidity,  as  in  going  back 
and  forth  from  the  excessively  dry  air  of  a  house  in  winter  to  the 
damp  air  outside,  the  demands  upon  the  mucous  membranes  are 
very  great  and  such  frequent  and  violent  changes  certainly  do  harm 
to  susceptible  people.  Such  rapid  variations  or  alterations  of  the 
humidity  of  the  inspired  air  I  think  are  as  bad  as  would  be  rapid 
alternations  of  altitude  involving  variations  of  several  thousand  feet. 

Some  patients,  however,  seem  to  do  better  with  a  humidity  greater 
than  that  chosen  for  others.     If  we  have  a  low  relative  humidity 


1  See  W.  Jarvis  Barlow,  M.  D. :    Climate  in  the  Treatment  of  Pulmonary 
Tuberculosis  (Journ.  Amer.  Medical  Association,  October  28,  1911). 


NO.    I  AIR   AND   TUBERCULOSIS — HINSDALE  133 

and  at  the  same  time  a  moderately  low  temperature  the  general 
effect  is  tonic  and  it  is  beneficial  in  conditions  of  irritability  *  f  the 
respiratory  mucous  membrane ;  but  if  the  temperature  is  very  low 
this  may  be  rather  irritating.  We  find  atmospheric  conditions  like 
this  from  Minnesota  to  the  Rockies  and  through  Manitoba  and 
Alberta. 

The  combination  of  high  relative  humidity  and  low  temperature 
certainly  favors  catarrh  and  we  have  such  conditions  all  winter 
long  in  the  region  of  the  Great  Lakes  and  in  New  York  and  New 
England.  Probably  the  best  combination  is  a  low  humidity  and  a 
moderately  cool  temperature ;  the  average  tuberculous  patient  makes 
his  best  gains  after  August  first  and  in  subsequent  cold,  dry  weather 
when  such  conditions  prevail.  But  of  course  there  are  exceptions 
and  some  do  better  with  a  high  relative  humidity  and  a  warm  tem- 
perature ;  these  are  not  numerous  and  probably  include  more  of  the 
patients  in  later  stages  when  expectoration  is  profuse  and  vitality  is 
low. 

The  old  idea  about  equability  of  temperature,  at  least  between  the 
temperature  of  midday  and  midnight,  is  not  of  great  importance ; 
all  mountainous  stations  show  great  variations  in  this  respect.  Some 
variability  tends  to  stimulate  the  vital  activities,  but  in  older  people 
and  those  who  are  feeble  great  variability  is  a  disadvantage. 

As  far  as  altitude  is  concerned  it  probably  has  not,  per  se,  any 
great  influence ;  certainly  to  my  mind  not  so  much  as  we  used  to 
think.  However,  altitude  is  incidentally  associated  with  mountain 
life  or  life  on  the  plains,  with  more  sun,  less  moisture,  and  scattered 
population.  We  should  not  forget  that  surgical  tuberculosis  is  al- 
ways favorably  influenced  by  a  seashore  residence  suitably  chosen. 
I  never  shall  forget  the  wonderful  impression  made  on  visiting 
the  Sea  Breeze  Hospital  for  Tuberculous  Children  on  Long  Island, 
New  York.  Constant  outdoor  life  in  all  weather  works  miraculous 
cures  after  the  "most  formidable  operations  for  bone  tuberculosis  and 
in  many  cases  renders  them  wholly  unnecessary  in  patients  whose 
physical  condition  on  admission  was  most  unpromising.  All  the 
great  French  and  Italian  sanatoria  for  tuberculous  children  are 
located  on  the  seashore. 

Among  the  numberless  histories  of  the  climatic  cure  I  will  give 
only  one  and  I  think  I  may  safely  let  it  stand  as  a  good  example  by 
which  to  let  the  argument  rest.  The  history  is  that  of  a  physician 
whom  we  all  love  and  respect.  It  was  published,  together  with 
twenty  other  carefully  recorded  histories,  by  that  prince  of  clinicians, 


134  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.    63 

the  late  Dr.  Alfred  L.  Loomis,  in  the  Medical  Record  and  formed 
a  parrof  a  paper  read  before  the  Medical  Society  of  the  State  of 
New  York  in  1879,  a  paper  which  we  commend  to  your  attention. 
Dr.  Loomis  says: 

At  the  age  of  twenty-five  this  patient,  being  of  good  family  history,  began 
to  lose  his  health  in  the  winter  of  1872.  His  symptoms  were  rapidly  becoming 
urgent;  he  was  examined  by  several  physicians.  Extensive  consolidation  at 
the  left  apex  was  found,  extending  posteriorly  nearly  to  the  angle  of  the 
scapula;  on  the  right  side  nothing  was  discovered  save  slight  pleuritic  ad- 
hesions at  the  apex. 

He  was  ordered  south,  but  returned  in  the  spring  in  no  way  benefited. 
On  the  contrary,  night-sweating  had  set  in,  and  his  fever  was  higher.  In 
the  latter  part  of  May  he  started  for  the  Adirondacks,  the  ride  in  the  stage 
being  accomplished  on  an  improvised  bed.  His  condition  at  this  time  was 
most  unpromising;  he  had  daily  fever,  night  sweats,  profuse  and  purulent 
expectoration,  had  lost  his  appetite  and  was  obliged  constantly  to  have 
recourse  to  stimulants.  Weight  about  134  pounds.  He  began  to  improve 
at  once,  his  appetite  returned,  all  his  symptoms  decreased  in  severity, 
and  after  a  stay  of  more  than  three  months  he  returned  to  New  York 
weighing  146  pounds,  with  only  slight  morning  cough,  presenting  the  appear- 
ance of  a  man  in  good  health.  A  few  days  after  his  arrival  in  New  York 
he  had  a  chill,  all  his  old  symptoms  returned  and  he  was  advised  to  leave 
for  St.  Paul,  Minnesota,  where  he  spent  the  entire  winter.  He  did  badly 
there;  was  sick  the  greater  portion  of  the  winter.  In  the  spring  of  1873 
he  again  went  to  the  Adirondacks.  At  this  time  he  was  in  a  most  debilitated 
state,  was  anemic,  emaciated,  had  daily  hectic  fever,  constant  cough,  and  pro- 
fuse purulent  expectoration. 

The  marked  improvement  did  not  commence  at  once  as  it  did  the  previous 
summer,  and  the  first  of  September  found  him  in  a  wretched  condition.  I 
then  examined  him  for  the  first  time  and  found  complete  consolidation  of  the 
left  lung  over  the  scapula  and  suprascapular  space,  with  pleuritic  thickenings 
and  adhesions  over  the  infraclavicular  space.  On  coughing,  bronchial  rales 
of  large  and  small  size  were  heard  over  the  consolidated  portion  of  the  lung. 
Over  the  right  infraclavicular  region  the  respiratory  murmur  was  feeble, 
and  on  full  inspiration  pleuritic  friction  sounds  were  heard.  I  advised  him 
to  remain  at  St.  Regis  Lake  during  the  winter,  and  although  he  was  repeatedly 
warned  that  such  a  step  would  prove  fatal,  he  followed  my  advice. 

From  this  time  he  began  slowly  to  improve.  Since  that  time  he  has  lived 
in  this  region.  At  the  present  time  his  weight  is  158  pounds,  gain  of  22 
pounds  since  he  first  went  to  the  Adirondacks  in  1873,  and  ten  pounds  more 
than  was  his  weight  in  health.  He  has  slight  morning  cough  and  expectora- 
tion, his  pulse  is  from  72  to  85  and  he  presents  the  appearance  of  a  person 
in  good  health.  In  his  lungs  evidences  still  remain  of  the  disease  he  has  so 
many  years  combated. 

Although  he  has  made  three  attempts  to  live  in  New  York,  at  intervals 
of  two  years,  each  time  his  removal  from  the  mountains  has  been  followed 
within  ten  days  by  a  chill,  and  a  return  of  pneumonic  symptoms — symptoms 
so  ominous  that  he  has  become  convinced  that  it  will  be  necessary  for  him 
to  remain  in  the  Adirondack  region  for  some  time  to  come. 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    I,    PL.    80 


.VI9B  WHR 


FIG.   1.     LOOMIS  SANATORIUM,  SULLIVAN  COUNTY,  NEW  YORK 


FIG.  2.     LOOMIS  SANATORIUM,  SULLIVAN  COUNTY,   NEW  YORK.     PORCH  OF  OLD  INFIRMARY 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    91 


PARTIAL  VIEW  OF  PENNSYLVANIA'S  STATE  SANATORIUM   FOR  TUBERCULOSIS    NUMBER   1, 
MONT  ALTO,  FRANKLIN   COUNTY 


.     ■ 


HAMBVRC  STATE  SAN&ORIVM 

:.:     SMMLL  C.DIXON  M.D.  COl.MSSQNTR 


FIG.  2.   PENNSYLVANIA'S  STATE  SANATORIUM   FOR  TUBERCULOSIS,   NUMBER  3,   HAMBURG, 

BERKS  COUNTY 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    83,      NO.    1,    PL     B2 


PARTIAL  VIEW  OF  PENNSYLVANIA'S  STATE  SANATORIUM   FOR  TUBERCULOSIS,   NUMBER  2, 

CRESSON,  CAMBRIA  COUNTY 

This  property,  formerly  a  popular  summer  resort  hotel,  was  presented  to  the  State   by  Mr. 

Andrew  Carnegie  for  sanatorium  purposes 


SMITHSONIAN    MISCELLANEOUS    COLLECTIONS 


VOL.    63,    NO.    1,    PL.    93 


THE  WALSH  WINDOW  TENT.      ALTHOUGH   LYING  IN  THE  BEDROOM  THE  SLEEPER    HAS  FREE 
ACCESS  TO  THE  OUTER  AIR 


NO.    I  AIR    AND   TUBERCULOSIS — HINSDALE  1.35 

We  all  know  the  after  history  of  this  patient.  Thank  God,  he  is 
still  living,  still  working,  and  there  are  thousands  living  to-day  who 
owe  their  lives  to  the  example  which  he  has  set  them.  He  seized  the 
principles  of  climatic  treatment  and  adapted  it  to  the  individual. 

I  recently  sent  the  following  question  to  the  deans  of  medical 
colleges  in  Boston,  Chicago,  New  Orleans,  Los  Angeles,  and  Mon- 
treal. I  knew  nothing  of  the  views  of  these  men  on  this  subject 
except  one ;  of  course  we  all  know  that  every  one  from  California 
has  decided  views  on  climate.    The  question  was : 

What  would  you  do  for  yourself  climatically  if  you  were  told  for 
the  first  time  that  you  had  incipient  pulmonary  tuberculosis? 

Here  are  the  answers:* 

I  would  strike  for  the  wild  pine  woods  of  northern  Michigan  or  Wisconsin 
and  stay  there. — A.  R.  Edwards,  Chicago. 

In  answer  to  your  question  I  may  say  that  if  I  had  incipient  tuberculosis 
I  should  either  go  to  Saranac  or  St.  Agathe  in  Canada  and  employ  the  open 
air  treatment. — F.  J.  Shepherd,  McGill  University,  Montreal. 

In  answer  to  your  question  of  December  26,  I  would  say  that  I  would 
treat  myself  as  I  do  patients  on  whom  I  make  the  diagnosis  of  incipient  pul- 
monary tuberculosis,  that  is,  refer  them  to  a  local  man  who  specializes  in  this 
disease,  and  ask  him  to  look  them  over  and  refer  them  for  climatic  treatment 
in  accordance  with  his  knowledge  of  climatic  conditions  suitable  to  the  indi- 
vidual case.  Were  I  to  start  out  to  select  a  climate  for  myself,  I  would  be 
much  more  influenced  by  the  physician  under  whose  care  I  would  come  in  the 
new  place  than  by  the  actual  climate,  and  would  probably  select  either  Saranac 
Lake  or  Asheville,  N.  C,  as  I  know  and  have  confidence  in  physicians  in  each 
place.  Were  they  to  decide  that  I  was  better  suited  to  some  other  climate, 
I  would  move  on  under  their  advice.  If  it  were  possible,  I  believe  that  I 
would  undoubtedly  leave  Boston,  had  I  incipient  tuberculosis. 

Very  truly  yours, 

Henry  A.   Christian, 

Boston. 

If  I  had  to  answer  your  question  categorically  I  would  say  that  I  would 
ask  the  advice  of  one  or  two  men  living  in  my  own  community  as  to  what 
I  should  do  for  myself  climatically  if  I  were  told  for  the  first  time  that  I 
had  incipient  pulmonary  tuberculosis. 

The  practice  among  the  profession  in  New  Orleans  is  to  send  patients  to 
St.  Tammany  Parish,  in  Louisiana,  where  the  growth  of  piney  woods  is  thick 
and  ozone  plentiful.  When  the  particular  case  justifies,  the  patient  is  sent 
to  the  plains  of  Arizona  or  New  Mexico,  and,  rarely,  to  El  Paso,  Texas.  A 
few  patients  go  to  Colorado. — Isadore  Dyer,  Tulane  University,  New  Or- 
leans, La. 

Perhaps  I  can  best  answer  this  personally  by  telling  you  what  I  did  when  I 
was  told  this  very  thing  fifteen  years  ago.  Having  contracted  tuberculosis 
in  New  York  city  I  sought  a  better  climate  for  an  outdoor  life,  spending 
the  first  summer  in  the  Adirondack  Mountains  and  in  November  of  that  year 


I36  SMITHSONIAN    MISCELLANEOUS    COLLECTIONS  VOL.   63 

going  to  California,  where  I  lived  for  one  year  in  the  foothill  region  near 
the  coast  at  an  elevatign  of  1,000  feet,  free  from  responsibility  and  work. 
After  the  first  year  I  never  had  any  return  of  my  pulmonary  tuberculosis. 

I  believe  a  change  of  climate  is  more  a  question  of  finances  than  anything 
else.  If  one  has  not  the  necessary  means  to  have  what  is  right  in  a  different 
climate  his  chances  for  a  cure  are  much  better  with  home  treatment,  but 
when  a  better  climate  can  conveniently  be  added  to  other  measures  of  treat- 
ment for  pulmonary  tuberculosis  it  should  be  advised. — W.  Jarvis  Barlow, 
Univ.  of  Southern  California,  Los  Angeles,  Cal. 

Note. — For  the  bibliography  of  tuberculosis  in  its  various  relations  the  reader 
is  referred  to  the  Index  Catalogue  of  the  Surgeon-General's  Library,  U.  S. 
Army,  Volume  18,  Second  Series,  Washington,  1913.  This  bibliography  em- 
braces 412  pages  in  double  columns,  an  invaluable  contribution  to  the  history 
and  literature  of  this  subject. 


COLUMBIA   UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

NfOV  ■  4«'3s 

, 

%b  i»  VSi 

C2B(638)M50 

